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
CASSANDRA DRUMMOND	AGENT	17366821		YES	8/15/2016
DIANE EBY	AGENT	17597856		YES	8/15/2016
MARY EHIAWAGUAN	AGENT	17332394		YES	8/15/2016
KIMBERLY HEROD	AGENT	17078330		YES	8/15/2016
TEMITOPE IGBAYILOLA	AGENT	17595679		YES	8/15/2016
CHRISTIAN JENNINGS	AGENT	17063310		YES	8/15/2016
BETTY KENNEDY	AGENT	17374607		YES	8/15/2016
MAUREEN MCDONALD	AGENT	16142127		YES	8/15/2016
CHRISTINE MENDENHALL	AGENT	17698683		YES	8/15/2016
TORSHANNA NOLES	AGENT	17044149		YES	8/15/2016
ANTHONY ROBINSON	AGENT	15972518		YES	8/15/2016
CHRISTINE ROSS	AGENT	17417354		YES	8/15/2016
DEDRIC WILLIAMS	AGENT	17658297		YES	8/15/2016

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