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
SHERIDAN HOBDY	AGENT	16680655		YES	01/31/2017
SHIRLEY MOORE	AGENT	17085478		YES	01/31/2017
SHRI GAUR	AGENT	1126906		YES	01/31/2017
STEPHANIE HARRIS	AGENT	17349948		YES	01/31/2017
STEPHEN BOX	AGENT	16865191		YES	01/31/2017
STEVEN WELP	AGENT	18030382		YES	01/31/2017
TANICIA CARTER	AGENT	17703763		YES	01/31/2017
TODD ROBINS	AGENT	9262191		YES	01/31/2017
TRACY CATO	AGENT	17613072		YES	01/31/2017
VADA GARDNER	AGENT	17370644		YES	01/31/2017
VASHELL WALKER	AGENT	17685893		YES	01/31/2017
VICKI LYNN	AGENT	18048349		YES	01/31/2017
VICTOR VARELA	AGENT	17665995		YES	01/31/2017
WILLIAM MORTIMER	AGENT	15887305		YES	01/31/2017
WILLIAM ROTH	AGENT	17015103		YES	01/31/2017

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