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
CORNELIA IRUENE	AGENT	17655164		YES	12/28/2016
LAKEIDRA JACKSON	AGENT	17080160		YES	12/28/2016
LAQUIRUS JACKSON	AGENT	17630091		YES	12/28/2016
OMAR JACKSON	AGENT	16771027		YES	12/28/2016
MADI JAGNE	AGENT	18058467		YES	12/28/2016
KHADIJAH JAMES	AGENT	17692124		YES	12/28/2016
BRITTANY JENKINS	AGENT	18059199		YES	12/28/2016
CHERRISH JOHNSON	AGENT	17655193		YES	12/28/2016
JAMIE JOHNSON	AGENT	16460640		YES	12/28/2016
LASHUNDRA JOHNSON	AGENT	17335702		YES	12/28/2016
MICHAEL JOHNSON	AGENT	7401057		YES	12/28/2016
TOMIKA JOHNSON	AGENT	17344986		YES	12/28/2016
JUANITA JOMON	AGENT	17073503		YES	12/28/2016
REGINALD JONES	AGENT	17358767		YES	12/28/2016
STEPHANIE JONES	AGENT	17640066		YES	12/28/2016

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