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:	8014150579
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
TERAH JAMES	BENEFIT ADVISOR	17640140		YES	5/20/2016
SCOTT JANCO	BENEFIT ADVISOR	17627479		YES	5/20/2016
BRANDY JENKINS	BENEFIT ADVISOR	17608341		YES	5/20/2016
VERONICA JIMERSON	BENEFIT ADVISOR	17335682		YES	5/20/2016
CHERRISH JOHNSON	BENEFIT ADVISOR	17655193		YES	5/20/2016
MONICA JOHNSON	BENEFIT ADVISOR	17583524		YES	5/20/2016
TOMIKA JOHNSON	BENEFIT ADVISOR	17344986		YES	5/20/2016
GLORIA JONES	BENEFIT ADVISOR	1269484		YES	5/20/2016
SHENA JONES	BENEFIT ADVISOR	17354280		YES	5/20/2016
STEPHANIE JONES	BENEFIT ADVISOR	17640066		YES	5/20/2016
PABLEA JUSTICE	BENEFIT ADVISOR	17021659		YES	5/20/2016
UZOAMAKA KELECHI-OPARA	BENEFIT ADVISOR	17613026		YES	5/20/2016
KOSTER KENNARD	BENEFIT ADVISOR	17039109		YES	5/20/2016
JOHN KENT	BENEFIT ADVISOR	17601705		YES	5/20/2016
NATHAN KING	BENEFIT ADVISOR	2073460		YES	5/20/2016

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