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
ANGEL COOK	BENEFIT ADVISOR	17370683	YES		5/19/2016
JOE COPELAND	BENEFIT ADVISOR	1285674	YES		5/19/2016
TIESHA COTTON	BENEFIT ADVISOR	17078334	YES		5/19/2016
VERNISHA CUFFEE-JOHNSON	BENEFIT ADVISOR	17357715	YES		5/19/2016
JACARRIA CURRY	BENEFIT ADVISOR	17673809	YES		5/19/2016
BRYAN DAVIS	BENEFIT ADVISOR	17653667	YES		5/19/2016
JAZZMIN DAVIS	BENEFIT ADVISOR	17653708	YES		5/19/2016
TEAISHA DAVIS	BENEFIT ADVISOR	17689308	YES		5/19/2016
KERRY DEAN	BENEFIT ADVISOR	17630017	YES		5/19/2016
EDWARD DELAHUNTY	BENEFIT ADVISOR	17363522	YES		5/19/2016
DONALD DEVITO	BENEFIT ADVISOR	17363181	YES		5/19/2016
MARGIE DOWNEY	BENEFIT ADVISOR	15363998	YES		5/19/2016
CASSANDRA DRUMMOND	BENEFIT ADVISOR	17366821	YES		5/19/2016
QHAWE DUBE	BENEFIT ADVISOR	17719816	YES		5/19/2016
ADDRIENA DUNCAN	BENEFIT ADVISOR	17369557	YES		5/19/2016

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