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:	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
ALICIA FRANK	AGENT	17030017		YES	12/28/2016
LOGAN FRAZEE	AGENT	18061265		YES	12/28/2016
DOUGLAS FRAZIER	AGENT	17589144		YES	12/28/2016
SHUNTANELLE FRAZIER	AGENT	18103606		YES	12/28/2016
LIZA FREEMAN	AGENT	17716792		YES	12/28/2016
CHARLENA FULLER	AGENT	17653723		YES	12/28/2016
ALAN GAGGINI	AGENT	17663760		YES	12/28/2016
ASHLEY GAMBLE	AGENT	17034663		YES	12/28/2016
SARA GANDY	AGENT	17583520		YES	12/28/2016
JUAN GARCIA	AGENT	18095146		YES	12/28/2016
LIZETTE GARCIA	AGENT	17103720		YES	12/28/2016
UMUTESI GASHABANA	AGENT	18048287		YES	12/28/2016
WESTON GILLEN	AGENT	17687676		YES	12/28/2016
MONICA GILLIS	AGENT	17640081		YES	12/28/2016
CHERILYN GINN	AGENT	17370690		YES	12/28/2016

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:	801-415-0579
Email Address:	LAC@EXTENDHEALTH.COM