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
DIANE HAMBRICK	AGENT	17049590		YES	12/28/2016
BRITTNEY HAMILTON	AGENT	17266841		YES	12/28/2016
MORGAN HAMILTON	AGENT	18103627		YES	12/28/2016
VANNESHA HAMILTON	AGENT	17624712		YES	12/28/2016
MELISSA HAMPTON	AGENT	17655200		YES	12/28/2016
JULIUS HARRIS	AGENT	16865138		YES	12/28/2016
PATRICIA HASENYAGER	AGENT	15763864		YES	12/28/2016
BRITTANI HILL	AGENT	17440985		YES	12/28/2016
MALCOLM HIMES	AGENT	17710022		YES	12/28/2016
RAJEEYAH HINES	AGENT	17371941		YES	12/28/2016
BEATRIZ HINOJOSA	AGENT	18062210		YES	12/28/2016
BRITTANY HOOKS	AGENT	17338103		YES	12/28/2016
BRANDON HOUSE	AGENT	17655125		YES	12/28/2016
YARSHEKA HOWARD THOMAS	AGENT	17579272		YES	12/28/2016
KELECHI IKWUEGBU	AGENT	17703838		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