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
DANDRA NEWMAN	AGENT	1288630		YES	12/29/2016
LAURA NEWREN	AGENT	8104281		YES	12/29/2016
HIEN NGUYEN	AGENT	17685796		YES	12/29/2016
SHANICE OBONNA	AGENT	17683527		YES	12/29/2016
SONYA OBONNA	AGENT	17658302		YES	12/29/2016
LACRETIA OLLIE	AGENT	17692120		YES	12/29/2016
OLUBUKOLA OSHOGBE	AGENT	17608338		YES	12/29/2016
BRIONNA OWENS	AGENT	17685801		YES	12/29/2016
JESSE OWENS	AGENT	17658207		YES	12/29/2016
SAMUEL OWUSU	AGENT	17752601		YES	12/29/2016
AVASHUN PACE	AGENT	17613099		YES	12/29/2016
JOHN PAIKOWSKI	AGENT	1132612		YES	12/29/2016
ABRAHAM PARKER	AGENT	18069875		YES	12/29/2016
GABRIELLE PATTERSON	AGENT	16850417		YES	12/29/2016
NICOLAS PENA	AGENT	17658296		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