Notification of Changes for Business Entity
General Information
Business Entity Name:	EXCHANGE 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:	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
FARHAD MOTAMED, GOLNAZ	BENEFIT ADVISOR	14677788	YES		12/30/15
FARREN, LESLIE	BENEFIT ADVISOR	17608223	YES		12/30/15
FEIL, DAVID	BENEFIT ADVISOR	16264532	YES		12/30/15
FELT, CHRISTOPHER	BENEFIT ADVISOR	17670009	YES		12/30/15
FERGUSON, JED	BENEFIT ADVISOR	7550395	YES		12/30/15
FERNANDEZ, ADAN	BENEFIT ADVISOR	16156871	YES		12/30/15
FERNANDEZ, KAREN	BENEFIT ADVISOR	17332328	YES		12/30/15
FERRIN, LARISSA	BENEFIT ADVISOR	17356171	YES		12/30/15
FEW, TERENA	BENEFIT ADVISOR	17071178	YES		12/30/15
FIELDS, BRYAN	BENEFIT ADVISOR	16774913	YES		12/30/15
FIELDS, LESLI	BENEFIT ADVISOR	16774818	YES		12/30/15
FILLMORE, MURLEEN	BENEFIT ADVISOR	17118168	YES		12/30/15
FINLAYSON, WENDY	BENEFIT ADVISOR	16928438	YES		12/30/15
FIRNGES, GORDON	BENEFIT ADVISOR	14819445	YES		12/30/15
FITZGERALD, JAMES	BENEFIT ADVISOR	13958172	YES		12/30/15

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