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
CAROLYNE TANUI	AGENT	17702762		YES	01/31/2017
CATHEY EVENSON	AGENT	17658181		YES	01/31/2017
CHARI SANGSTER	AGENT	17049525		YES	01/31/2017
CHARLES NEAL	AGENT	17705252		YES	01/31/2017
CHENETTA MCRAE EBE	AGENT	17641009		YES	01/31/2017
CHERISH ROBINSON	AGENT	17673905		YES	01/31/2017
CHERYL LANGSTON	AGENT	17674708		YES	01/31/2017
CLETUS IGUNBOR	AGENT	17583515		YES	01/31/2017
CLIFTON MUHAMMAD	AGENT	10448276		YES	01/31/2017
COLINA ROBINSON	AGENT	17015490		YES	01/31/2017
DANIEL BREITENSTEIN	AGENT	17318118		YES	01/31/2017
DAVID BURNS	AGENT	1210084		YES	01/31/2017
DAVID SANDERS	AGENT	1250459		YES	01/31/2017
DEBRA FIELDS	AGENT	17015580		YES	01/31/2017
DENNIS JOHANSEN	AGENT	15817919		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