Notification of Changes for Business Entity
General Information
Business Entity Name:	EXCHANGE 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:	19075 STERLING VIEW DRIVE
Address 2:	SUITE A-1
City:	SOUTH JORDAN
State:	UT
Zip:	84095
Phone:	8014150579
Fax:
Business Web Site Address:
Business Email Address:	LAC@EXTENDHEALTH.COM
Mailing Address
Address 1:	19075 STERLING VIEW DRIVE
Address 2:	SUITE A-1
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
ENNIS, KATHLEEN	BENEFIT ADVISOR	17485799	YES		12/30/15
EPPERSON, CARMEN	BENEFIT ADVISOR	1168009	YES		12/30/15
ERICKSON, JACOB	BENEFIT ADVISOR	16714987	YES		12/30/15
ERNST, JUDY	BENEFIT ADVISOR	5444500	YES		12/30/15
ERWIN, TIFFANY	BENEFIT ADVISOR	17348807	YES		12/30/15
ESCHLER, JONATHAN	BENEFIT ADVISOR	8814167	YES		12/30/15
ESTES, FASHIONETTE	BENEFIT ADVISOR	17036048	YES		12/30/15
ETIER, PIERRE	BENEFIT ADVISOR	1261948	YES		12/30/15
EVANS, BRADLEY	BENEFIT ADVISOR	17336285	YES		12/30/15
EVANS, MARVIN	BENEFIT ADVISOR	10413683	YES		12/30/15
EVANS, TERRIE	BENEFIT ADVISOR	4572233	YES		12/30/15
EVERETT, JAMES	BENEFIT ADVISOR	5447940	YES		12/30/15
EZEJI, DIANE	BENEFIT ADVISOR	17029940	YES		12/30/15
FAIRLEY, AMBER	BENEFIT ADVISOR	17089126	YES		12/30/15
FANTROY, ARIANA	BENEFIT ADVISOR	17035995	YES		12/30/15

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