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
GARY, BARBARA	BENEFIT ADVISOR	17328207	YES		12/30/15
GAST, SUSAN	BENEFIT ADVISOR	16708900	YES		12/30/15
GASTILE, JASMINE	BENEFIT ADVISOR	17335701	YES		12/30/15
GAUDETTE, MILLER	BENEFIT ADVISOR	16344239	YES		12/30/15
GAUR, SHRI	BENEFIT ADVISOR	1126906	YES		12/30/15
GAY, BRANDI	BENEFIT ADVISOR	11161024	YES		12/30/15
GILBERT, STEVEN	BENEFIT ADVISOR	16306365	YES		12/30/15
GILES, TAMARA	BENEFIT ADVISOR	17612980	YES		12/30/15
GILLEN, WESTON	BENEFIT ADVISOR	17687676	YES		12/30/15
GILLIS, MONICA	BENEFIT ADVISOR	17640081	YES		12/30/15
GILSTRAP, CANDICE	BENEFIT ADVISOR	17608348	YES		12/30/15
GINN, CHERILYN	BENEFIT ADVISOR	17370690	YES		12/30/15
GIVENS-WALLACE, ALICIA	BENEFIT ADVISOR	17062588	YES		12/30/15
GLASER, PATRICIA	BENEFIT ADVISOR	16595226	YES		12/30/15
GLATER, MARGO	BENEFIT ADVISOR	17328348	YES		12/30/15

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