Notification of Changes for Business Entity
General Information
Business Entity Name:	EXTEND INSURANCE SERVICES, LLC
Incorporation / Formation Date:
FEIN:	202487260
Ohio License Number:	32852
NPN:	8415824
DBA / Trade Name:
State of Domicile:	UT
County:	SALT LAKE
Business Address
Address 1:	10975 S. STERLING VIEW DRIVE
Address 2:
City:	SOUTH JORDAN
State:	UT
Zip:	84095
Phone:	8014150579
Fax:
Business Web Site Address:
Business Email Address:	LAC@EXTENDHEALTH.COM
Mailing Address
Address 1:	10975 S. STERLING VIEW DRIVE
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
NYE, DORIAN	BENEFIT ADVISOR	5451647	YES		12/31/15
OBONNA, SONYA	BENEFIT ADVISOR	17658302	YES		12/31/15
ODOM, CRAIG	BENEFIT ADVISOR	1085010	YES		12/31/15
OGERO, YUNES	BENEFIT ADVISOR	17698692	YES		12/31/15
OHLIN, MICHAEL	BENEFIT ADVISOR	16727833	YES		12/31/15
OKUSAMI, OLUFEMI	BENEFIT ADVISOR	17515427	YES		12/31/15
OLIVER, IVAN	BENEFIT ADVISOR	1069504	YES		12/31/15
OLIVER, KAREN	BENEFIT ADVISOR	2765982	YES		12/31/15
OLLIE, LACRETIA	BENEFIT ADVISOR	17692120	YES		12/31/15
OMBATI, ATANAS	BENEFIT ADVISOR	17615870	YES		12/31/15
ORFANOS, WILLIAM	BENEFIT ADVISOR	14656781	YES		12/31/15
OROZCO, JANETTE	BENEFIT ADVISOR	17584823	YES		12/31/15
OSHOGBE, OLUBUKOLA	BENEFIT ADVISOR	17608338	YES		12/31/15
OTUSI, GODFREY	BENEFIT ADVISOR	11137253	YES		12/31/15
OVESON, DAVID	BENEFIT ADVISOR	16682513	YES		12/31/15

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 AND CHIEF TECHNOLOGY OFFICER
Phone Number:	8014150579
Email Address:	LAC@EXTENDHEALTH.COM