Notification of Changes for Business Entity
General Information
Business Entity Name:	EXTEND INSURANCE SERVICES
Incorporation / Formation Date:
FEIN:	202487260
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	UT
County:	SALT LAKE
Business Address
Address 1:	10975 S STERLING VIEW DR, STE A1
Address 2:
City:	SOUTH JORDAN
State:	UT
Zip:	84095
Phone:	801-415-0579
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	10975 S STERLING VIEW DR, STE A1
Address 2:
City:	SOUTH JORDAN
State:	UT
Zip:	84095
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	NO	Old Business Entity Name:
New DBA/Trade Name:	NO	New DBA/Trade Name:
Amend DBA/Trade Name:	NO	Old DBA/Trade Name:
Add/Delete Producers, Members, Owners, Partners, Officers and/or Directors:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
ERIN JUDD	AGENT	18028008	YES		09/22/2016
SASHA KABARTAY	AGENT	18095162	YES		09/22/2016
NANCI KASSEL	AGENT	16442414	YES		09/22/2016
WESLEY KEATON	AGENT	18030363	YES		09/22/2016
LARRY KILPATRICK	AGENT	18034808	YES		09/22/2016
CHATNEY KING	AGENT	18095064	YES		09/22/2016
ALLEN KIRABO	AGENT	17670483	YES		09/22/2016
BILL KIRKLAND	AGENT	18083920	YES		09/22/2016
TAMARA KNIGHT TRIGG	AGENT	18088574	YES		09/22/2016
RICHARD KOSGEI	AGENT	17328384	YES		09/22/2016
JEAN LACOBEE	AGENT	17670454	YES		09/22/2016
TIERRA LACY	AGENT	18083947	YES		09/22/2016
LISA LAFFITY	AGENT	18103660	YES		09/22/2016
NIKAYLA LAKES	AGENT	18048300	YES		09/22/2016
SHA RAYVIOUS LAMPKIN	AGENT	18095087	YES		09/22/2016

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date

Title Business Entities Only
1. Is any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance? (i.e. banking, auto dealer, mortgage company)
2. Has any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance since the filing of the previous CN-65 or the original application?
3. If the answer to questions #1 or #2 is yes, identify the business or profession and the nature of person's involvement

Submitted By
Submitted By:	CAMERON LILJENQUIST
Title:	SVP & CHIEF TECHNOLOGY OFFICER
Phone Number:	8014150579
Email Address:	LAC@EXTENDHEALTH.COM