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
TYMESHA REED	AGENT	17641298		YES	12/29/2016
CHEVEL RENIER	AGENT	17335617		YES	12/29/2016
MELISSA RICHARDS	AGENT	17085359		YES	12/29/2016
ADRIAN RIGGS	AGENT	18023376		YES	12/29/2016
IRVING RIVERA PUGH	AGENT	10390416		YES	12/29/2016
JUAN RIVERA QUINONES	AGENT	17349817		YES	12/29/2016
BRITTANEY ROBERSON MORRISON	AGENT	17641289		YES	12/29/2016
JIDA ROBERTSON	AGENT	17595563		YES	12/29/2016
SHAMEKA ROBINSON	AGENT	17659670		YES	12/29/2016
SARAI RODRIGUEZ SALDANA	AGENT	17095421		YES	12/29/2016
ZHAMARYA ROGERS	AGENT	18030293		YES	12/29/2016
LOUISE ROTHSCHILD	AGENT	17641162		YES	12/29/2016
RUTH RUIZ	AGENT	17692144		YES	12/29/2016
SIMBISAI RUPUNGU	AGENT	18088561		YES	12/29/2016
VALENESE SAMPSON	AGENT	17590019		YES	12/29/2016

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