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
ANTHONY PATE	BENEFIT ADVISOR	17329579	YES		5/20/2016
LACHANETTE PATRICK	BENEFIT ADVISOR	17332238	YES		5/20/2016
LAQUITA PINKARD	BENEFIT ADVISOR	17071081	YES		5/20/2016
CHARLENE RATHBURN	BENEFIT ADVISOR	17085358	YES		5/20/2016
TYMESHA REED	BENEFIT ADVISOR	17641298	YES		5/20/2016
JAMES REEVE	BENEFIT ADVISOR	17595571	YES		5/20/2016
EULICIA RELIFORD	BENEFIT ADVISOR	17023665	YES		5/20/2016
JUAN RIVERA-QUINONES	BENEFIT ADVISOR	17349817	YES		5/20/2016
BRITTANEY ROBERSON MORRISON	BENEFIT ADVISOR	17641289	YES		5/20/2016
CHANDRA ROBINSON	BENEFIT ADVISOR	7679785	YES		5/20/2016
LAQUESHIA ROBISON	BENEFIT ADVISOR	17358743	YES		5/20/2016
MELISSA RODRIGUEZ	BENEFIT ADVISOR	17038149	YES		5/20/2016
SARAI RODRIGUEZ	BENEFIT ADVISOR	17095421	YES		5/20/2016
LATANYA RUFF	BENEFIT ADVISOR	17071092	YES		5/20/2016
TONIA RUIZ	BENEFIT ADVISOR	17597806	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