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
HEIDI DUKE	AGENT	17002094		YES	12/28/2016
ADDRIENA DUNCAN	AGENT	17369557		YES	12/28/2016
ASHLEY EASTER	AGENT	17584810		YES	12/28/2016
DARRIUS EASTER	AGENT	17640151		YES	12/28/2016
SHARI EDWARDS	AGENT	17049632		YES	12/28/2016
THAMEETHA EDWARDS	AGENT	17703821		YES	12/28/2016
SHAMIRA ELDRIDGE	AGENT	17358780		YES	12/28/2016
DANIELLE ELLIOTT	AGENT	17655206		YES	12/28/2016
OCTAVIA ELLISON	AGENT	17363608		YES	12/28/2016
ADAN FERNANDEZ	AGENT	16156871		YES	12/28/2016
LANDON FLETCHER	AGENT	17360839		YES	12/28/2016
DONNA FLORES	AGENT	17365444		YES	12/28/2016
HELEN FOARD BEDELL	AGENT	17685881		YES	12/28/2016
CHRISTINA FORNEY	AGENT	17719808		YES	12/28/2016
AMY FOWLER	AGENT	17071126		YES	12/28/2016

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