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:	8014150579
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
JOSHUA DAVIS	BENEFIT ADVISOR	17008615		YES	5/20/2016
JOY DEGROAT	BENEFIT ADVISOR	17685868		YES	5/20/2016
TRACI DELANEY	BENEFIT ADVISOR	17040985		YES	5/20/2016
HEIDI DUKE	BENEFIT ADVISOR	17002094		YES	5/20/2016
DARRIUS EASTER	BENEFIT ADVISOR	17640151		YES	5/20/2016
SAMETRIA EATON	BENEFIT ADVISOR	17602269		YES	5/20/2016
TIFFANY ERWIN	BENEFIT ADVISOR	17348807		YES	5/20/2016
BRADLEY EVANS	BENEFIT ADVISOR	17336285		YES	5/20/2016
TERRIE EVANS	BENEFIT ADVISOR	4572233		YES	5/20/2016
DAVID FEIL	BENEFIT ADVISOR	16264532		YES	5/20/2016
SATAURUS FOSTER	BENEFIT ADVISOR	17658235		YES	5/20/2016
EDWARD FOWLER	BENEFIT ADVISOR	5458049		YES	5/20/2016
CRISTOBAL FRAIRE	BENEFIT ADVISOR	17034948		YES	5/20/2016
DOUGLAS FRAZIER	BENEFIT ADVISOR	17589144		YES	5/20/2016
NANCY FREDERICK	BENEFIT ADVISOR	1417521		YES	5/20/2016

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:	8014150579
Email Address:	LAC@EXTENDHEALTH.COM