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:
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
BROOKS, BENJAMIN	BENEFIT ADVISOR	15645687	YES		12/22/15
BROTHERS, LARRY	BENEFIT ADVISOR	16597593	YES		12/22/15
BROTHWELL, JAMILYN	BENEFIT ADVISOR	14666529	YES		12/22/15
BROUGHTON, CHYNTHA	BENEFIT ADVISOR	17036011	YES		12/22/15
BROUSSARD, HARLAN	BENEFIT ADVISOR	15889840	YES		12/22/15
BROWN, ASHLEY	BENEFIT ADVISOR	17349923	YES		12/22/15
BROWN, DEMETRIUS	BENEFIT ADVISOR	17049516	YES		12/22/15
BROWN, JOEL	BENEFIT ADVISOR	16689415	YES		12/22/15
BROWN, KENDRIA	BENEFIT ADVISOR	17044169	YES		12/22/15
BROWN, MELODY	BENEFIT ADVISOR	17340873	YES		12/22/15
BROYLES, AMANDA	BENEFIT ADVISOR	17063305	YES		12/22/15
BROYLES, CHRISTOPHER	BENEFIT ADVISOR	17590083	YES		12/22/15
BRUCE, SANDRA	BENEFIT ADVISOR	17045334	YES		12/22/15
BRUNER, AJOY	BENEFIT ADVISOR	17285928	YES		12/22/15
BRUNER, LEE	BENEFIT ADVISOR	1900192			12/22/15

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