Notification of Changes for Business Entity
General Information
Business Entity Name:	EXCHANGE 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:	19075 STERLING VIEW DRIVE
Address 2:	SUITE A-1
City:	SOUTH JORDAN
State:	UT
Zip:	84095
Phone:	8014150579
Fax:
Business Web Site Address:
Business Email Address:	LAC@EXTENDHEALTH.COM
Mailing Address
Address 1:	19075 STERLING VIEW DRIVE
Address 2:	SUITE A-1
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
FRENCH, CORETTA	BENEFIT ADVISOR	16262053	YES		12/30/15
FRIESON, RAKEISHA	BENEFIT ADVISOR	17369425	YES		12/30/15
FUGATE, JUSTIN	BENEFIT ADVISOR	17114714	YES		12/30/15
FULLER, CHARLENA	BENEFIT ADVISOR	17653723	YES		12/30/15
FUNG, ANTOINETTE	BENEFIT ADVISOR	17063298	YES		12/30/15
FURLONG, KENDALL	BENEFIT ADVISOR	17097608	YES		12/30/15
FURR, JAMES	BENEFIT ADVISOR	235266	YES		12/30/15
GAGGINI, ALAN	BENEFIT ADVISOR	17663760	YES		12/30/15
GARCIA, LISA	BENEFIT ADVISOR	17045321	YES		12/30/15
GARCIA, MARIA	BENEFIT ADVISOR	16900723	YES		12/30/15
GARCIA, SKYE	BENEFIT ADVISOR	17328350	YES		12/30/15
GARDNER, VADA	BENEFIT ADVISOR	17370644	YES		12/30/15
GARNICA, ERIKA	BENEFIT ADVISOR	16279354	YES		12/30/15
GARRETT, DAVID	BENEFIT ADVISOR	5452422	YES		12/30/15
GARRITY, ADELINE	BENEFIT ADVISOR	1587513	YES		12/30/15

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