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
CECELIA KIRKWOOD	BENEFIT ADVISOR	10890035		YES	5/20/2016
MICHAEL KNOWLES	BENEFIT ADVISOR	15000139		YES	5/20/2016
VIRAH KONG	BENEFIT ADVISOR	17683489		YES	5/20/2016
SARITA KUMAR	BENEFIT ADVISOR	17328258		YES	5/20/2016
GINA LARSON	BENEFIT ADVISOR	1294125		YES	5/20/2016
KNYOKA LAWSON	BENEFIT ADVISOR	17078437		YES	5/20/2016
LAWRENCE LEVINE	BENEFIT ADVISOR	17072240		YES	5/20/2016
CHIKEYTA LEWIS	BENEFIT ADVISOR	17703703		YES	5/20/2016
DANIEL LEWIS	BENEFIT ADVISOR	7073777		YES	5/20/2016
LADONNA LEWIS	BENEFIT ADVISOR	17658244		YES	5/20/2016
SHARI LOCKE	BENEFIT ADVISOR	17332313		YES	5/20/2016
ASKI LOCKETT	BENEFIT ADVISOR	17692232		YES	5/20/2016
REKKIAH LOUDEN	BENEFIT ADVISOR	17555508		YES	5/20/2016
JAMES MANGUM	BENEFIT ADVISOR	17658114		YES	5/20/2016
ELLE MARRERO	BENEFIT ADVISOR	15786174		YES	5/20/2016

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