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
SHARI EDWARDS	BENEFIT ADVISOR	17049632	YES		5/19/2016
THAMEETHA EDWARDS	BENEFIT ADVISOR	17703821	YES		5/19/2016
SHAMIRA ELDRIDGE	BENEFIT ADVISOR	17358780	YES		5/19/2016
OCTAVIA ELLISON	BENEFIT ADVISOR	17363608	YES		5/19/2016
CATHEY EVENSON	BENEFIT ADVISOR	17658181	YES		5/19/2016
HELEN FOARD-BEDELL	BENEFIT ADVISOR	17685881	YES		5/19/2016
JOY FREEMAN	BENEFIT ADVISOR	17059349	YES		5/19/2016
LIZA FREEMAN	BENEFIT ADVISOR	17716792	YES		5/19/2016
ASHLEY GAMBLE	BENEFIT ADVISOR	17034663	YES		5/19/2016
AMBRIA GIBSON	BENEFIT ADVISOR	17087777	YES		5/19/2016
SHANDICE GONZALEZ	BENEFIT ADVISOR	17349858	YES		5/19/2016
GABRIEL GRADY	BENEFIT ADVISOR	17670496	YES		5/19/2016
ANGEL HANKINS-CRENSHAW	BENEFIT ADVISOR	17655203	YES		5/19/2016
JULIUS HARRIS	BENEFIT ADVISOR	16865138	YES		5/19/2016
MYEISHA HENRY	BENEFIT ADVISOR	17059287	YES		5/19/2016

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