Notification of Changes for Business Entity
General Information
Business Entity Name:	EXTEND INSURANCE SERVICES, LLC
Incorporation / Formation Date:
FEIN:	202487260
Ohio License Number:	32852
NPN:	8415824
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
MORIN, HEIDI	BENEFIT ADVISOR	17344990	YES		12/31/15
MORIN, LAWRENCE	BENEFIT ADVISOR	16912219	YES		12/31/15
MORLEY, TERRY	BENEFIT ADVISOR	5461115	YES		12/31/15
MORRIS, CARYL	BENEFIT ADVISOR	17716860	YES		12/31/15
MORRISON, VICTORIA	BENEFIT ADVISOR	17715461	YES		12/31/15
MORROW, CHRISTINA	BENEFIT ADVISOR	17584827	YES		12/31/15
MORTIMER, WILLIAM	BENEFIT ADVISOR	15887305	YES		12/31/15
MOSBY, ALVIN	BENEFIT ADVISOR	8916944	YES		12/31/15
MOSLEY, SHARUN	BENEFIT ADVISOR	17685847	YES		12/31/15
MOSSER, MICHELE	BENEFIT ADVISOR	9740048	YES		12/31/15
MOTIWALA, MUHAMMAD BILAL	BENEFIT ADVISOR	17597767	YES		12/31/15
MOTONGO, DAVID	BENEFIT ADVISOR	10611529	YES		12/31/15
MUHAMMAD, CLIFTON	BENEFIT ADVISOR	10448276	YES		12/31/15
MUKOLU, CLETUS	BENEFIT ADVISOR	17641220	YES		12/31/15
MULVIHILL, JIM	BENEFIT ADVISOR	7066212	YES		12/31/15

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