Notification of Changes for Business Entity
General Information
Business Entity Name:	EXCHANGE 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:	19075 STERLING VIEW DRIVE
Address 2:	SUITE A-1
City:	SOUTH JORDAN
State:	UT
Zip:	84095
Phone:	8014150579
Fax:
Business Web Site Address:
Business Email Address:	LAC@EXTENDHEALTH.COM
Mailing Address
Address 1:	19075 STERLING VIEW DRIVE
Address 2:	SUITE A-1
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:	EXCHANGE INSURANCE SERVICES, L
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
BYERLY, BRITTANEY	BENEFIT ADVISOR	17360841	YES		12/29/2015
CAFFEY, CECILIA	BENEFIT ADVISOR	16717523	YES		12/29/2015
CALDERON, KELLY	BENEFIT ADVISOR	17623667	YES		12/29/2015
CALDWELL, CECILY	BENEFIT ADVISOR	17658140	YES		12/29/2015
CALDWELL, MONICA	BENEFIT ADVISOR	17655116	YES		12/29/2015
CALLAHAN, CAROLE	BENEFIT ADVISOR	16292897	YES		12/29/2015
CALLAWAY, DEBRA	BENEFIT ADVISOR	664037	YES		12/29/2015
CAMBRE, LASHON	BENEFIT ADVISOR	17332329	YES		12/29/2015
CAMPBELL, BARBARA	BENEFIT ADVISOR	889983	YES		12/29/2015
CAREY, JACQUITHA	BENEFIT ADVISOR	17358820	YES		12/29/2015
CARLTON, DAVID	BENEFIT ADVISOR	17032647	YES		12/29/2015
CARROLL, CHRISTOPHER	BENEFIT ADVISOR	17349927	YES		12/29/2015
CARROLL, MARY ANN	BENEFIT ADVISOR	17037054	YES		12/29/2015
CARTER, CAMERON	BENEFIT ADVISOR	17339820	YES		12/29/2015
CARTER, CARROLL	BENEFIT ADVISOR	16339153	YES		12/29/2015

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