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:	801-415-0579
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
MICHAEL MILLS	BENEFIT ADVISOR	17658099	YES		6/30/2016
KEIUNTE MORGAN	BENEFIT ADVISOR	17029916	YES		6/30/2016
VICTORIA MORRISON	BENEFIT ADVISOR	17715461	YES		6/30/2016
CHRISTINA MORROW	BENEFIT ADVISOR	17584827	YES		6/30/2016
CLETUS MUKOLU	BENEFIT ADVISOR	17641220	YES		6/30/2016
JODI NASH	BENEFIT ADVISOR	17658119	YES		6/30/2016
STARR NAVEJAS	BENEFIT ADVISOR	17344857	YES		6/30/2016
CHARLES NEAL	BENEFIT ADVISOR	17705252	YES		6/30/2016
LAKEIDRA NEAL	BENEFIT ADVISOR	17673808	YES		6/30/2016
TONI NELSON	BENEFIT ADVISOR	1633559	YES		6/30/2016
DELORES NESBIT	BENEFIT ADVISOR	17658218	YES		6/30/2016
LAURA NEWREN	BENEFIT ADVISOR	8104281	YES		6/30/2016
HIEN NGUYEN	BENEFIT ADVISOR	17685796	YES		6/30/2016
MELINDA NGUYEN	BENEFIT ADVISOR	17624592	YES		6/30/2016
TORSHANNA NOLES	BENEFIT ADVISOR	17044149	YES		6/30/2016

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