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 DRIVE, 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 DRIVE, 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
COMFORT EDEM	AGENT	18083986		YES	10/25/2016
LAWRENCE ESSEL	AGENT	17349814		YES	10/25/2016
SHEILA FLAX	AGENT	16955870		YES	10/25/2016
MARY FOSTER	AGENT	17332173		YES	10/25/2016
CORETTA FRENCH	AGENT	16262053		YES	10/25/2016
ERIC FRY	AGENT	13927576		YES	10/25/2016
NAUTICA GAINES	AGENT	18082226		YES	10/25/2016
GARY GARDNER	AGENT	13708537		YES	10/25/2016
RUSHUNDRIA GILBERT	AGENT	18082166		YES	10/25/2016
CHRISTOPHER GRANT	AGENT	17709989		YES	10/25/2016
KENDRA HARMON	AGENT	17008626		YES	10/25/2016
YVONNE HARRAL	AGENT	6968380		YES	10/25/2016
EVERARDO HERNANDEZ RAMIREZ	AGENT	17692223		YES	10/25/2016
MOHAMMED HOSSAIN	AGENT	18034990		YES	10/25/2016
TRACY ISAAC	AGENT	17685851		YES	10/25/2016

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