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:	84085
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
CIARA THOMAS	AGENT	18126188		YES	12/29/2016
FRANK TRAVER	AGENT	1152205		YES	12/29/2016
KELSI TRESCO	AGENT	17798161		YES	12/29/2016
ANITA TRYON	AGENT	17696305		YES	12/29/2016
DONNA TURNER	AGENT	18050062		YES	12/29/2016
PATRICK UMELO	AGENT	17218298		YES	12/29/2016
ALISHA VANORSBY	AGENT	18030387		YES	12/29/2016
IMRAN VARACHIA	AGENT	17683503		YES	12/29/2016
KIMBERLY VASQUEZ	AGENT	18083929		YES	12/29/2016
ANA VILLANUEVA MEDINA	AGENT	18049999		YES	12/29/2016
DALVIN WADE	AGENT	18034907		YES	12/29/2016
KEITH WADE	AGENT	18067597		YES	12/29/2016
WINDELL WALTERS	AGENT	17624644		YES	12/29/2016
KIARA WARREN	AGENT	17584835		YES	12/29/2016
CHAMARRA WASHINGTON	AGENT	17328436		YES	12/29/2016

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