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 DRIVE, 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
RASHIDA ADAIR	AGENT	17378580	YES		08/08/2016
LUIS AROCHO	AGENT	17085401	YES		08/08/2016
BASSAM AYOOB	AGENT	17654735	YES		08/08/2016
TEMBERLEY BAILEY	AGENT	17021478	YES		08/08/2016
MICHAEL BLACKSHIRE	AGENT	17332275	YES		08/08/2016
BEVERLY BONNER	AGENT	17338040	YES		08/08/2016
CHEVAELLA BRIGGS	AGENT	17613053	YES		08/08/2016
JACQUITHA CAREY	AGENT	17358820	YES		08/08/2016
EFFIE CLEWIS	AGENT	17048229	YES		08/08/2016
CARLOS COLON	AGENT	17073459	YES		08/08/2016
GERMAN CONTRERAS MARCIA	AGENT	17362053	YES		08/08/2016
SARAH COOK	AGENT	17665347	YES		08/08/2016
SHANAE COOK	AGENT	17329123	YES		08/08/2016
O JOSHUA COON	AGENT	17703582	YES		08/08/2016
INGRID DANCER	AGENT	17703700	YES		08/08/2016

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