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
SANDRA RAY	BENEFIT ADVISOR	8790045		YES	5/20/2016
LACHANDRA REED	BENEFIT ADVISOR	17203817		YES	5/20/2016
KADIJAH RICKS	BENEFIT ADVISOR	17659690		YES	5/20/2016
ROSEMARY RIDDLE-STEWART	BENEFIT ADVISOR	17362013		YES	5/20/2016
JOHN RIDER	BENEFIT ADVISOR	17051407		YES	5/20/2016
TIANA RILEY	BENEFIT ADVISOR	17673819		YES	5/20/2016
IRVING RIVERA PUGH	BENEFIT ADVISOR	10390416		YES	5/20/2016
GREGORY RODGERS	BENEFIT ADVISOR	17673838		YES	5/20/2016
GRACIE RODRIGUEZ	BENEFIT ADVISOR	17597857		YES	5/20/2016
KAREN ROSS	BENEFIT ADVISOR	17349886		YES	5/20/2016
AUGUSTIN RUBIO	BENEFIT ADVISOR	17384749		YES	5/20/2016
SHERRY RUSSELL	BENEFIT ADVISOR	1247840		YES	5/20/2016
DAVID SANDERS	BENEFIT ADVISOR	1250459		YES	5/20/2016
RICHARD SCHERBA	BENEFIT ADVISOR	1246419		YES	5/20/2016
KIMESHA SCOTT	BENEFIT ADVISOR	17651539		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