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
PERSEPHANIE REED	BENEFIT ADVISOR	17070116	YES		6/30/2016
CHEVEL RENIER	BENEFIT ADVISOR	17335617	YES		6/30/2016
ERIC RHODES	BENEFIT ADVISOR	17683497	YES		6/30/2016
RAYNARD RICHARDSON	BENEFIT ADVISOR	17332931	YES		6/30/2016
ALYSSA RICKS	BENEFIT ADVISOR	17634942	YES		6/30/2016
JOHN RIDER	BENEFIT ADVISOR	17051407	YES		6/30/2016
NICOLA RILEY	BENEFIT ADVISOR	17362124	YES		6/30/2016
SHANNAH RILEY	BENEFIT ADVISOR	9466874	YES		6/30/2016
ANTHONY ROBINSON	BENEFIT ADVISOR	17608286	YES		6/30/2016
COLINA ROBINSON	BENEFIT ADVISOR	17015490	YES		6/30/2016
SHAMEKA ROBINSON	BENEFIT ADVISOR	17659670	YES		6/30/2016
GREGORY RODGERS	BENEFIT ADVISOR	17673838	YES		6/30/2016
PATRICE ROSE	BENEFIT ADVISOR	17589054	YES		6/30/2016
KAREN ROSS	BENEFIT ADVISOR	17349886	YES		6/30/2016
LESLEY RUIZ	BENEFIT ADVISOR	17641315	YES		6/30/2016

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