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
THOMAS, KIMBERLY	BENEFIT ADVISOR	17042053	YES		12/31/15
THOMASON, MARIN	BENEFIT ADVISOR	11516732	YES		12/31/15
THOMPSON, BILLIE	BENEFIT ADVISOR	4590341	YES		12/31/15
THOMPSON, FREDERICK	BENEFIT ADVISOR	14786483	YES		12/31/15
THOMPSON, KANDASIA	BENEFIT ADVISOR	17338073	YES		12/31/15
THOMPSON, MICHAEL	BENEFIT ADVISOR	17146967	YES		12/31/15
THOMPSON, QUANNAH	BENEFIT ADVISOR	17355386	YES		12/31/15
THOMSON, CHRISTOPHER	BENEFIT ADVISOR	17042858	YES		12/31/15
THORUP, BRAEDEN	BENEFIT ADVISOR	8382648	YES		12/31/15
TIDWELL, MARTHA	BENEFIT ADVISOR	17021467	YES		12/31/15
TILLEY-OPPENHAMMER, BRANDI	BENEFIT ADVISOR	17624649	YES		12/31/15
TIMON, STEPHANIE	BENEFIT ADVISOR	17659700	YES		12/31/15
TISDALE, WILLIAM	BENEFIT ADVISOR	17045338	YES		12/31/15
TOMAH, JEFFERY	BENEFIT ADVISOR	16748073	YES		12/31/15
TOME, BRUNO	BENEFIT ADVISOR	17589069	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