Notification of Changes for Business Entity
General Information
Business Entity Name:	EXTEND INSURANCE SERVICES, LLC
Incorporation / Formation Date:
FEIN:	202487260
Ohio License Number:	32852
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
SMITH, MATTHEW	BENEFIT ADVISOR	16769625	YES		12/31/15
SMITH, SCOTT	BENEFIT ADVISOR	15992667	YES		12/31/15
SMITH, SHAWNTAE	BENEFIT ADVISOR	16743076	YES		12/31/15
SMITH, TASMINE	BENEFIT ADVISOR	17087092	YES		12/31/15
SMITH, TIMOTHY	BENEFIT ADVISOR	9503523	YES		12/31/15
SMITH, TYLER	BENEFIT ADVISOR	17519920	YES		12/31/15
SNYDER, BRIAN	BENEFIT ADVISOR	10144255	YES		12/31/15
SOK, PHALLY	BENEFIT ADVISOR	17683471	YES		12/31/15
SOLOMON, MATT	BENEFIT ADVISOR	17032660	YES		12/31/15
SOLOMON, RISA	BENEFIT ADVISOR	17031969	YES		12/31/15
SORENSON, LARISSA	BENEFIT ADVISOR	15903154	YES		12/31/15
SOTELO, CESAR	BENEFIT ADVISOR	17063248	YES		12/31/15
SPEAD, MARSHAY	BENEFIT ADVISOR	17328295	YES		12/31/15
SPEASMAKER, LAURA	BENEFIT ADVISOR	15957029	YES		12/31/15
SPENCER, GEOFFREY	BENEFIT ADVISOR	17071164	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