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
CRITTENDON, GENESE	BENEFIT ADVISOR	17618877	YES		12/29/15
CROFT, PAMELA	BENEFIT ADVISOR	16270460	YES		12/29/15
CROPP, BARBARA	BENEFIT ADVISOR	17064096	YES		12/29/15
CROWLEY, MICHAEL	BENEFIT ADVISOR	16157601	YES		12/29/15
CRUMP, MAKENZIE	BENEFIT ADVISOR	17348311	YES		12/29/15
CRUZ, LORENZO	BENEFIT ADVISOR	17613018	YES		12/29/15
CUE, SHEENA	BENEFIT ADVISOR	17655137	YES		12/29/15
CUMMINGS, CHRISTOPHER	BENEFIT ADVISOR	7842813	YES		12/29/15
CUMMINGS, MARTENA	BENEFIT ADVISOR	17338138	YES		12/29/15
CURRINGTON, ARCHIE	BENEFIT ADVISOR	17692185	YES		12/29/15
CUSTODIO, AMY	BENEFIT ADVISOR	17665357	YES		12/29/15
D'ARNALL, DENNIS	BENEFIT ADVISOR	5461831	YES		12/29/15
DABBS, SHARKETA	BENEFIT ADVISOR	17060392	YES		12/29/15
DAMRON, JEAN-PAUL	BENEFIT ADVISOR	16686438	YES		12/29/15
DARATA, DAVID	BENEFIT ADVISOR	16264538	YES		12/29/15

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