Notification of Changes for Business Entity
General Information
Business Entity Name:	EXCHANGE 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:	19075 STERLING VIEW DRIVE
Address 2:	SUITE A-1
City:	SOUTH JORDAN
State:	UT
Zip:	84095
Phone:	8014150579
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	19075 STERLING VIEW DRIVE
Address 2:	SUITE A-1
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
BENDER, BILLIE	BENEFIT ADVISOR	17072300	YES		12/22/15
BENNETT, KATINA	BENEFIT ADVISOR	17673843	YES		12/22/15
BERNARD, NANCY	BENEFIT ADVISOR	16739613	YES		12/22/15
BESHEARS, THOMAS	BENEFIT ADVISOR	16769589	YES		12/22/15
BEST, LAURA	BENEFIT ADVISOR	16746259	YES		12/22/15
BEST, MELISSA	BENEFIT ADVISOR	17039106	YES		12/22/15
BIALO, SHARI-LYN	BENEFIT ADVISOR	17031331	YES		12/22/15
BIASATTI, STEVEN	BENEFIT ADVISOR	14910480	YES		12/22/15
BILTON, AMANDA	BENEFIT ADVISOR	17583400	YES		12/22/15
BIRD, JANICE	BENEFIT ADVISOR	16155484	YES		12/22/15
BISHOP, JORDAN	BENEFIT ADVISOR	17008654	YES		12/22/15
BISHOP, ROBERT	BENEFIT ADVISOR	17665411	YES		12/22/15
BITUM, GENEROUS	BENEFIT ADVISOR	17692189	YES		12/22/15
BLACK, FLOYD	BENEFIT ADVISOR	16864898	YES		12/22/15
BLACK, RICHARD	BENEFIT ADVISOR	16727882	YES		12/22/15

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