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:	10975 S. STERLING VIEW DRIVE
Address 2:
City:	SOUTH JORDAN
State:	UT
Zip:	84095
Phone:	8014150579
Fax:
Business Web Site Address:
Business Email Address:	LAC@EXTENDHEALTH.COM
Mailing Address
Address 1:	10975 S. STERLING VIEW DRIVE
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
PATTERSON, GABRIELLE	BENEFIT ADVISOR	16850417	YES		12/31/15
PATTERSON, KENNETH	BENEFIT ADVISOR	15947120	YES		12/31/15
PATTERSON, SCOTT	BENEFIT ADVISOR	17329161	YES		12/31/15
PAUL, MARLA	BENEFIT ADVISOR	17021594	YES		12/31/15
PAUSTENBAUGH, LAURA	BENEFIT ADVISOR	17008661			12/31/15
PELEMO, KEHINDE	BENEFIT ADVISOR	17584931	YES		12/31/15
PERKINS, DIANNE	BENEFIT ADVISOR	17015585	YES		12/31/15
PERKINS, JOCELYN	BENEFIT ADVISOR	17610755	YES		12/31/15
PERSON, BELINDA	BENEFIT ADVISOR	17050402	YES		12/31/15
PETERS, CAROLEE	BENEFIT ADVISOR	7616507	YES		12/31/15
PETERS, WAYNE	BENEFIT ADVISOR	17376755	YES		12/31/15
PETERSEN, JUSTINE	BENEFIT ADVISOR	17051398	YES		12/31/15
PETERSON, ELOISA	BENEFIT ADVISOR	17037003	YES		12/31/15
PETERSON, MILLICENT	BENEFIT ADVISOR	17615782	YES		12/31/15
PHYNES, WINFORT	BENEFIT ADVISOR	17344976	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