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 DRIVE, STE A1
Address 2:
City:	SOUTH JORDAN
State:	UT
Zip:	84095
Phone:	18014150579
Fax:
Business Web Site Address:
Business Email Address:	LAC@WILLISTOWERSWATSON.COM
Mailing Address
Address 1:	10975 S STERLING VIEW DRIVE, 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
MELISSA CODDINGTON	AGENT	16292898	YES		12/05/2018
JANET DAVIS	AGENT	16528335	YES		12/05/2018
WILFRED IGNACE	AGENT	15904001	YES		12/05/2018
BRIAN JAWORSKI	AGENT	15879787	YES		12/05/2018
RONNI KATZ	AGENT	14786501	YES		12/05/2018
RICHARD MCCULLOUGH	AGENT	13080173	YES		12/05/2018
REBECCA MELTON	AGENT	7872933	YES		12/05/2018
DAVID MOTONGO	AGENT	10611529	YES		12/05/2018
RANDOLPH ST GEORGE	AGENT	1326378	YES		12/05/2018
BRENT WALLER	AGENT	16383639	YES		12/05/2018
JAMES WILSON	AGENT	16304836	YES		12/05/2018

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:	18014150579
Email Address:	LAC@WILLISTOWERSWATSON.COM