Notification of Changes for Business Entity
General Information
Business Entity Name:	EXTEND INSURANCE SERVICES
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
AQUEELAH ABDULLAH	AGENT	18082241	YES		09/22/2016
HILTON ADOLINAMA	AGENT	17539063	YES		09/22/2016
LUCKY AHANENE	AGENT	18030281	YES		09/22/2016
JOHN AKERS	AGENT	17442640	YES		09/22/2016
BILLIE ALDRIDGE	AGENT	18082214	YES		09/22/2016
SOPHIA ALEXANDER	AGENT	17114575	YES		09/22/2016
KARIMI ALONZO	AGENT	18066415	YES		09/22/2016
DULCE AMAYA MERAZ	AGENT	18030311	YES		09/22/2016
AMANDRA ANDERSON	AGENT	18048305	YES		09/22/2016
FAYE ANDERSON	AGENT	18030330	YES		09/22/2016
ELICIA ARCHIBALD	AGENT	18030236	YES		09/22/2016
RAVEN BAILEY	AGENT	18034875	YES		09/22/2016
KAMWANNA BAKER	AGENT	18060644	YES		09/22/2016
ARTANDRA BALLARD	AGENT	18103577	YES		09/22/2016
COURTNEY BEASLEY	AGENT	18092977	YES		09/22/2016

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