Notification of Changes for Business Entity
General Information
Business Entity Name:	EXTEND INSURANCE SERVICES
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
STEPHANIE FOYGOMWALK	AGENT	18045788	YES		09/22/2016
LOGAN FRAZEE	AGENT	18061265	YES		09/22/2016
SHUNTANELLE FRAZIER	AGENT	18103606	YES		09/22/2016
ERIC FRY	AGENT	13927576	YES		09/22/2016
MELISA GADI	AGENT	18083924	YES		09/22/2016
NAUTICA GAINES	AGENT	18082226	YES		09/22/2016
JUAN GARCIA	AGENT	18095146	YES		09/22/2016
UMUTESI GASHABANA	AGENT	18048287	YES		09/22/2016
AROMA GELANI	AGENT	18084062	YES		09/22/2016
JAMIE GENEMATAS	AGENT	17998993	YES		09/22/2016
TWILA GIBSON	AGENT	18056802	YES		09/22/2016
RUSHUNDRIA GILBERT	AGENT	18082166	YES		09/22/2016
EUNICE GILL	AGENT	18093015	YES		09/22/2016
CHERILYN GINN	AGENT	17370690	YES		09/22/2016
ASHLEY GOLTZ	AGENT	18034963	YES		09/22/2016

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