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
JOSHUA COLE	AGENT	17059901		YES	11/28/2016
BOBBIE COLLIER	AGENT	16521222		YES	11/28/2016
JACARRIA CURRY	AGENT	17673809		YES	11/28/2016
LAKESHA DUNCAN	AGENT	18084058		YES	11/28/2016
NANCY ECHOLS	AGENT	17071141		YES	11/28/2016
SUSAN GAST	AGENT	16708900		YES	11/28/2016
SCHMEKA GREEN	AGENT	17608387		YES	11/28/2016
SCHMYRA GREEN	AGENT	18048353		YES	11/28/2016
STEPHEN GRICE	AGENT	17692147		YES	11/28/2016
YOLUNDA HAMILTON	AGENT	17374510		YES	11/28/2016
MICHAEL HERRINGTON	AGENT	1175023		YES	11/28/2016
AUDREY HIPPS	AGENT	17027541		YES	11/28/2016
SHYKENDRA HOLLOWAY	AGENT	17608321		YES	11/28/2016
JASMINE HOWARD ROBINSON	AGENT	18083978		YES	11/28/2016
EFOSA IGHODARO	AGENT	17576613		YES	11/28/2016

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:	801-415-0579
Email Address:	LAC@EXTENDHEALTH.COM