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:	10975 S. STERLING VIEW DRIVE
Address 2:
City:	SOUTH JORDAN
State:	UT
Zip:	84095
Phone:	8014150579
Fax:
Business Web Site Address:
Business Email Address:	LAC@EXTENDHEALTH.COM
Mailing Address
Address 1:	10975 S. STERLING VIEW DRIVE
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
WEINBERGER, CLAUDIA	BENEFIT ADVISOR	16751143	YES		12/31/15
WEIS, PAMELA	BENEFIT ADVISOR	1309014	YES		12/31/15
WEISS, TRACIE	BENEFIT ADVISOR	17357309	YES		12/31/15
WELLS, JAMES	BENEFIT ADVISOR	17098639	YES		12/31/15
WERNER, ADAM	BENEFIT ADVISOR	17694246	YES		12/31/15
WESSON, STEPHEN	BENEFIT ADVISOR	11549660	YES		12/31/15
WEST, DAVID	BENEFIT ADVISOR	17624660	YES		12/31/15
WHEELER, LACY	BENEFIT ADVISOR	17054276	YES		12/31/15
WHITE, ALVONDA	BENEFIT ADVISOR	17673883	YES		12/31/15
WHITE, JENNIFER	BENEFIT ADVISOR	17612986	YES		12/31/15
WHITE, KIMBERLIN	BENEFIT ADVISOR	17106276	YES		12/31/15
WHITEHEAD, PAUL	BENEFIT ADVISOR	17651499	YES		12/31/15
WHITESEL, SHIRLEY	BENEFIT ADVISOR	17051406	YES		12/31/15
WHITING, JEREMY	BENEFIT ADVISOR	16727896	YES		12/31/15
WHITMER, MICHAEL	BENEFIT ADVISOR	16779330	YES		12/31/15

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