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:	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
JETER, LAWANDA	BENEFIT ADVISOR		YES		12/30/15
JIMERSON, VERONICA	BENEFIT ADVISOR		YES		12/30/15
JOHANSEN, DENNIS	BENEFIT ADVISOR		YES		12/30/15
JOHN, BRENDA	BENEFIT ADVISOR		YES		12/30/15
JOHNS, NATHAN	BENEFIT ADVISOR		YES		12/30/15
JOHNSON, ANGELA	BENEFIT ADVISOR		YES		12/30/15
JOHNSON, CHARLINE	BENEFIT ADVISOR		YES		12/30/15
JOHNSON, CHERRISH	BENEFIT ADVISOR		YES		12/30/15
JOHNSON, LATONYA	BENEFIT ADVISOR		YES		12/30/15
JOHNSON, LYNDA	BENEFIT ADVISOR		YES		12/30/15
JOHNSON, MICHAEL	BENEFIT ADVISOR		YES		12/30/15
JOHNSON, MONICA	BENEFIT ADVISOR		YES		12/30/15
JOHNSON, ROBERT	BENEFIT ADVISOR		YES		12/30/15
JOHNSON, TOMIKA	BENEFIT ADVISOR		YES		12/30/15
JOHNSTON, RODNEY	BENEFIT ADVISOR		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