Notification of Changes for Business Entity
General Information
Business Entity Name:	EXTEND INSURANCE SERVICES, LLC
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
KHALILAH BROWN	AGENT	17673795		YES	12/28/2016
STEPHEN BROWNE	AGENT	14657124		YES	12/28/2016
MARLENE BULLARD	AGENT	15837468		YES	12/28/2016
JAHN BURNS	AGENT	17029999		YES	12/28/2016
DEBRA BURROW	AGENT	18048338		YES	12/28/2016
TRENTON BUTLER	AGENT	17708032		YES	12/28/2016
TERRY BYAS	AGENT	17803031		YES	12/28/2016
JONISE BYRD WEBB	AGENT	16689826		YES	12/28/2016
BRITTANY CALDWELL	AGENT	18030420		YES	12/28/2016
CHRISTINA CARTER	AGENT	17658269		YES	12/28/2016
CHYNNA CARTER	AGENT	17037111		YES	12/28/2016
COLLITTA CARTER	AGENT	17719802		YES	12/28/2016
REAGAN CARTER	AGENT	18030384		YES	12/28/2016
JAERICA CHAMBERS	AGENT	18034803		YES	12/28/2016
SASHA CHOI	AGENT	17667025		YES	12/28/2016

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:	801-415-0579
Email Address:	LAC@EXTENDHEALTH.COM