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:
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
CHAMISA, MANNERS	BENEFIT ADVISOR	16298883	YES		12/29/15
CHAN, RICHARD	BENEFIT ADVISOR	17363591	YES		12/29/15
CHENEY, MARYANN	BENEFIT ADVISOR	12780760	YES		12/29/15
CHENNELL, SHERI	BENEFIT ADVISOR	17332258	YES		12/29/15
CHIHURI, JULIANA	BENEFIT ADVISOR	17344977	YES		12/29/15
CHOI, SASHA	BENEFIT ADVISOR	17667025	YES		12/29/15
CHRISTENSEN, ROBERT	BENEFIT ADVISOR	16811730	YES		12/29/15
CHRYST, JEFFREY	BENEFIT ADVISOR	5454316	YES		12/29/15
CISSE, TSHEA	BENEFIT ADVISOR	17576509	YES		12/29/15
CLARK, BEVERLY	BENEFIT ADVISOR	17338075	YES		12/29/15
CLARK, HARLOW	BENEFIT ADVISOR	15886274	YES		12/29/15
CLARK THOMAS, SHERRY	BENEFIT ADVISOR	17629957	YES		12/29/15
CLAY, RICKY	BENEFIT ADVISOR	17083671	YES		12/29/15
CLAYTON, ISAAC	BENEFIT ADVISOR	17692213	YES		12/29/15
CLEMENTS, ASIA	BENEFIT ADVISOR	17692226	YES		12/29/15

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