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:	8014150579
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
ERIC HERNANDEZ	BENEFIT ADVISOR	17616890	YES		5/19/2016
DONSHAE HICKS	BENEFIT ADVISOR	17651429	YES		5/19/2016
DOMINIQUE HOGG	BENEFIT ADVISOR	17613052	YES		5/19/2016
JEREMY HOWELL	BENEFIT ADVISOR	17273956	YES		5/19/2016
CLETUS IGUNBOR	BENEFIT ADVISOR	17583515	YES		5/19/2016
TRACY ISAAC	BENEFIT ADVISOR	17685851	YES		5/19/2016
ADONDESS JACKSON	BENEFIT ADVISOR	17355352	YES		5/19/2016
REGINA JACKSON	BENEFIT ADVISOR	17376752	YES		5/19/2016
ANDREA JENSEN	BENEFIT ADVISOR	16694671	YES		5/19/2016
CARL JOHNSON	BENEFIT ADVISOR	11570233	YES		5/19/2016
LASHUNDRA JOHNSON	BENEFIT ADVISOR	17335702	YES		5/19/2016
MICHAEL JOHNSON	BENEFIT ADVISOR	7401057	YES		5/19/2016
ROBERT JOHNSON	BENEFIT ADVISOR	11309452	YES		5/19/2016
RONNETTA JOHNSON	BENEFIT ADVISOR	17071031	YES		5/19/2016
JUANITA JOMON	BENEFIT ADVISOR	17073503	YES		5/19/2016

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:	8014150579
Email Address:	LAC@EXTENDHEALTH.COM