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
ALANA HILL	AGENT	16735882		YES	01/31/2017
ALLISON VILLANUEVA	AGENT	18063091		YES	01/31/2017
ALMAZ TELAHUN	AGENT	17328357		YES	01/31/2017
ALYSSA RICKS	AGENT	17634942		YES	01/31/2017
ANGEL HARRIS	AGENT	1286511		YES	01/31/2017
ARCHIE CURRINGTON	AGENT	17692185		YES	01/31/2017
AROMA GELANI	AGENT	18084062		YES	01/31/2017
ASKI LOCKETT	AGENT	17692232		YES	01/31/2017
BARBARA CROPP	AGENT	17064096		YES	01/31/2017
BELINDA GREEN	AGENT	18016395		YES	01/31/2017
BENJAMIN JARMAN	AGENT	17665336		YES	01/31/2017
BILL KIRKLAND	AGENT	18083920		YES	01/31/2017
BILLIE BENDER	AGENT	17072300		YES	01/31/2017
BILLIE ALDRIDGE	AGENT	18082214		YES	01/31/2017
BRENDA JOHN	AGENT	17340887		YES	01/31/2017

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