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
CHVYONNE PAUL	AGENT	17576554		YES	11/28/2016
DARRIOUS POLK	AGENT	17183714		YES	11/28/2016
PERSEPHANIE REED	AGENT	17070116		YES	11/28/2016
ERIC RHODES	AGENT	17683497		YES	11/28/2016
KAREN ROSS	AGENT	17349886		YES	11/28/2016
BRENDA SANDOVAL	AGENT	17710939		YES	11/28/2016
DONNA SEWELL	AGENT	18066463		YES	11/28/2016
SEANNA SHIRER	AGENT	17673830		YES	11/28/2016
MOSTAFA SHUBBAR	AGENT	17624597		YES	11/28/2016
J HERBERT SIGMON	AGENT	16835097		YES	11/28/2016
PAULA SIMMONS	AGENT	17818612		YES	11/28/2016
LINDA SIMONS	AGENT	17659684		YES	11/28/2016
JO SIMS	AGENT	17060296		YES	11/28/2016
CODI SIZEMORE	AGENT	16387882		YES	11/28/2016
CHATERICA SMITH	AGENT	17085450		YES	11/28/2016

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:	801-415-0579
Email Address:	LAC@EXTENDHEALTH.COM