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
ROBERT TAYLOR	BENEFIT ADVISOR	17328463	YES		5/20/2016
JEFFREY THOMAS	BENEFIT ADVISOR	17015454	YES		5/20/2016
FRANK TRAVER	BENEFIT ADVISOR	1152205	YES		5/20/2016
DANNY TRUSSELL	BENEFIT ADVISOR	1303198	YES		5/20/2016
JESSICA TURNER	BENEFIT ADVISOR	17696334	YES		5/20/2016
ROSHUNDA TURNER	BENEFIT ADVISOR	17031889	YES		5/20/2016
PHILIPPE TYE	BENEFIT ADVISOR	13166422	YES		5/20/2016
AMY VALENTINE	BENEFIT ADVISOR	17335643	YES		5/20/2016
KENNETH VANN	BENEFIT ADVISOR	7552388	YES		5/20/2016
IMRAN VARACHIA	BENEFIT ADVISOR	17683503	YES		5/20/2016
DEEDEE VILLARREAL	BENEFIT ADVISOR	17670061	YES		5/20/2016
ELIZABETH VILLARREAL	BENEFIT ADVISOR	17049556	YES		5/20/2016
NICHOLAS WASHINGTON	BENEFIT ADVISOR	8780954	YES		5/20/2016
SARA WATTS	BENEFIT ADVISOR	17583520	YES		5/20/2016
NICOLE WHITE	BENEFIT ADVISOR	16728367	YES		5/20/2016

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