Notification of Changes for Business Entity
General Information
Business Entity Name:	EXTEND INSURANCE SERVICES, LLC
Incorporation / Formation Date:
FEIN:	202487260
Ohio License Number:	3
NPN:	8415824
DBA / Trade Name:
State of Domicile:	UT
County:	SALT LAKE
Business Address
Address 1:	10975 S. STERLING VIEW DRIVE
Address 2:
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 S. STERLING VIEW DRIVE
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
SEARLES-SMITH, KRISTOPHER	BENEFIT ADVISOR	14656789	YES		12/31/15
SHAH, SYED	BENEFIT ADVISOR	17692164	YES		12/31/15
SHARIF, SHADMAN	BENEFIT ADVISOR	17659640	YES		12/31/15
SHARP, LISA	BENEFIT ADVISOR	16715047	YES		12/31/15
SHAW, BARRY	BENEFIT ADVISOR	17080124	YES		12/31/15
SHED, ROBBIE	BENEFIT ADVISOR	17049587	YES		12/31/15
SHEPHERD, BEVERLY	BENEFIT ADVISOR	16736571	YES		12/31/15
SHIRLEY, GEOFFREY	BENEFIT ADVISOR	17108168	YES		12/31/15
SHOAF, BRYAN	BENEFIT ADVISOR	5460584	YES		12/31/15
SHOEMAKER, PAULINE	BENEFIT ADVISOR	16730565	YES		12/31/15
SHURTLEFF, JASON	BENEFIT ADVISOR	17694800	YES		12/31/15
SIERRA, STACEY	BENEFIT ADVISOR	8615763	YES		12/31/15
SILVERMAN, LLOYD	BENEFIT ADVISOR	837628	YES		12/31/15
SIMMONS, JANEEN	BENEFIT ADVISOR	17338091	YES		12/31/15
SIMONS, LINDA	BENEFIT ADVISOR	17659684	YES		12/31/15

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