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:	18014150579
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
DEBORAH KIEFIUK	AGENT	16211268	YES		8/21/2018
PATTI POWELL	AGENT	16730578	YES		8/21/2018
ADRIAN RIGGS	AGENT	18023376	YES		8/21/2018
ALICIA PRITCHARD	AGENT	18802420	YES		8/21/2018
LINDA JONES	AGENT	3139261	YES		8/21/2018
FRANKLIN GRAFFUIS	AGENT	17084390	YES		8/21/2018
FELICIA GOUVEIA	AGENT	17670123	YES		8/21/2018
MARQUESHA JAMES	AGENT	18467724	YES		8/21/2018
TRINA JACKSON	AGENT	18783779	YES		8/21/2018
CARRIE KAERCHER	AGENT	8235228	YES		8/21/2018
LEWIS SCHULTZ	AGENT	1267966	YES		8/21/2018
GEORGE ROGERS	AGENT	18837230	YES		8/21/2018
ATLANTIS PIERRE	AGENT	16386426	YES		8/21/2018
DEBRA COBBETT	AGENT	18492209	YES		8/21/2018
SAARA CASTILHO	AGENT	16508499	YES		8/21/2018

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
DAVID FEIL

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:	18014150579
Email Address:	LAC@WILLISTOWERSWATSON.COM