Notification of Changes for Business Entity
General Information
Business Entity Name:	EXTEND INSURANCE SERVICES
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
SHANEEQUA MCCLELLAN	BENEFIT ADVISOR	17392152		YES	09/26/2016
DAGIM MELKA	BENEFIT ADVISOR	17658325		YES	09/26/2016
CHELSEA NELSON	BENEFIT ADVISOR	16288213		YES	09/26/2016
KELLY PEEBLES	BENEFIT ADVISOR	17671977		YES	09/26/2016
ERIK RAYBON	BENEFIT ADVISOR	17073505		YES	09/26/2016
LACHANDRA REED	BENEFIT ADVISOR	17203817		YES	09/26/2016
ROBERT RIPPY	BENEFIT ADVISOR	17335355		YES	09/26/2016
IRINA ROBISON	BENEFIT ADVISOR	15946826		YES	09/26/2016
MELISSA RODRIGUEZ	BENEFIT ADVISOR	17038149		YES	09/26/2016
TONIA RUIZ	BENEFIT ADVISOR	17597806		YES	09/26/2016
LY ROSE SHIELDS	BENEFIT ADVISOR	17021587		YES	09/26/2016
ARRIELLE SHORTER	BENEFIT ADVISOR	17648282		YES	09/26/2016
JASON SHURTLEFF	BENEFIT ADVISOR	17694800		YES	09/26/2016
CHELSEY TERRY	BENEFIT ADVISOR	17673922		YES	09/26/2016
TIMEKA TYLER	BENEFIT ADVISOR	17340812		YES	09/26/2016

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