Notification of Changes for Business Entity
General Information
Business Entity Name:	EXTEND INSURANCE SERVICES, LLC
Incorporation / Formation Date:
FEIN:	202487260
Ohio License Number:	32852
NPN:	8415824
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:	10975 STERLING VIEW DIRVE
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
HARRIS, LAMONICA	BENEFIT ADVISOR	17049524	YES		12/30/15
HARRIS, STEPHANIE	BENEFIT ADVISOR	17349948	YES		12/30/15
HART, THOMAS	BENEFIT ADVISOR	16796420	YES		12/30/15
HASENYAGER, PATRICIA	BENEFIT ADVISOR	15763864	YES		12/30/15
HATCH, HOLLY	BENEFIT ADVISOR	17330367	YES		12/30/15
HAYES, TIMOTHY	BENEFIT ADVISOR	17262116	YES		12/30/15
HAYMORE, ROBIN	BENEFIT ADVISOR	17589118	YES		12/30/15
HAYNES, CHEKELAH	BENEFIT ADVISOR	17021546	YES		12/30/15
HEALY, MICHAEL	BENEFIT ADVISOR	17328178	YES		12/30/15
HELINE, ANDREA	BENEFIT ADVISOR	16759310	YES		12/30/15
HENDERSON, KE'AMBRA	BENEFIT ADVISOR	17624578	YES		12/30/15
HENDERSON, KOQUICE	BENEFIT ADVISOR	17624595	YES		12/30/15
HENSLEY, DAMON	BENEFIT ADVISOR	15708702	YES		12/30/15
HERNANDEZ, KARA	BENEFIT ADVISOR	16905345	YES		12/30/15
HERRINGTON, MICHAEL	BENEFIT ADVISOR	1175023	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