Notification of Changes for Business Entity
General Information
Business Entity Name:	EXTEND INSURANCE SERVICES
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:	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
ANGIE DAVIS	AGENT	18034971	YES		09/22/2016
IESHA DAVIS	AGENT	18084019	YES		09/22/2016
ROGER DAVIS	AGENT	6732568	YES		09/22/2016
MYASHIA DEAN	AGENT	18082108	YES		09/22/2016
BARBARA DEATON	AGENT	1232641	YES		09/22/2016
FAYE DEBOUGH	AGENT	15793333	YES		09/22/2016
LATWASHIA DILLARD	AGENT	18037276	YES		09/22/2016
LAKESHA DUNCAN	AGENT	18084058	YES		09/22/2016
ASHLEY EASTER	AGENT	17584810	YES		09/22/2016
COMFORT EDEM	AGENT	18083986	YES		09/22/2016
BRYAN ELDREDGE	AGENT	6748403	YES		09/22/2016
JASMINE ETIER	AGENT	17710021	YES		09/22/2016
DEBRA FIELDS	AGENT	17015580	YES		09/22/2016
SHANIKA FONTENO	AGENT	18083960	YES		09/22/2016
CHRISTINA FORNEY	AGENT	17719808	YES		09/22/2016

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