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 DRIVE, 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
MICHAEL AKPOGUMA	BENEFIT ADVISOR	17658132	YES		6/30/2016
ALEXIS ALEX	BENEFIT ADVISOR	17708059	YES		6/30/2016
WYNETHA ALEXANDER	BENEFIT ADVISOR	16935069	YES		6/30/2016
BRIAN ANDERSON	BENEFIT ADVISOR	1249591	YES		6/30/2016
MELODY ANDREWS	BENEFIT ADVISOR	17749819	YES		6/30/2016
RICHARD ANTHONY	BENEFIT ADVISOR	34858	YES		6/30/2016
CHRISTOPHER ARTHUR	BENEFIT ADVISOR	17063268	YES		6/30/2016
CHRISTINA ASH	BENEFIT ADVISOR	16779239	YES		6/30/2016
MARYANN ASHBURN	BENEFIT ADVISOR	17659674	YES		6/30/2016
ANAM ASHRAF	BENEFIT ADVISOR	17608420	YES		6/30/2016
LATASHA BANKS	BENEFIT ADVISOR	17608403	YES		6/30/2016
EZRA BARROGA	BENEFIT ADVISOR	17697032	YES		6/30/2016
LA TONYA BEARD	BENEFIT ADVISOR	17658086	YES		6/30/2016
CHARLEENE BEASLEY	BENEFIT ADVISOR	17658295	YES		6/30/2016
RHONDA BECKMAN	BENEFIT ADVISOR	17063316	YES		6/30/2016

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