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
ANNA KELLENBERGER	BENEFIT ADVISOR	17685875	YES		5/19/2016
TONY KELLER	BENEFIT ADVISOR	17063234	YES		5/19/2016
YOLANDA KIRKS	BENEFIT ADVISOR	17670551	YES		5/19/2016
SARAH KLINGER	BENEFIT ADVISOR	16750007	YES		5/19/2016
CHERYL LANGSTON	BENEFIT ADVISOR	17674708	YES		5/19/2016
NKIRUKA LAZZ ONYENOBI	BENEFIT ADVISOR	17712478	YES		5/19/2016
VANESHA LEE	BENEFIT ADVISOR	17021585	YES		5/19/2016
BOBBY LEQUIA	BENEFIT ADVISOR	16344276	YES		5/19/2016
DORIS LIGON-ANABA	BENEFIT ADVISOR	17097631	YES		5/19/2016
TERRYL LIPPERT	BENEFIT ADVISOR	17063275	YES		5/19/2016
MICHELLE LOVELESS	BENEFIT ADVISOR	17305110	YES		5/19/2016
DANA LYDIA	BENEFIT ADVISOR	17021554	YES		5/19/2016
NORMAN MACMANN	BENEFIT ADVISOR	17015409	YES		5/19/2016
JESSICA MARION	BENEFIT ADVISOR	17624658	YES		5/19/2016
MIGUEL MARTINEZ	BENEFIT ADVISOR	17360847	YES		5/19/2016

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