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
BRENDA SANDOVAL	BENEFIT ADVISOR	17710939	YES		6/30/2016
RICHARD SCHERBA	BENEFIT ADVISOR	1246419	YES		6/30/2016
ALYCE SCHMITT	BENEFIT ADVISOR	17354276	YES		6/30/2016
DONNA SCIARA	BENEFIT ADVISOR	17665991	YES		6/30/2016
MARKIESIA SCOTT	BENEFIT ADVISOR	17147006	YES		6/30/2016
SHADMAN SHARIF	BENEFIT ADVISOR	17659640	YES		6/30/2016
DANIELLE SHEPARD	BENEFIT ADVISOR	17683408	YES		6/30/2016
MOSTAFA SHUBBAR	BENEFIT ADVISOR	17624597	YES		6/30/2016
JO SIMS	BENEFIT ADVISOR	17060296	YES		6/30/2016
CARLONDA SMITH	BENEFIT ADVISOR	17624723	YES		6/30/2016
CHATERICA SMITH	BENEFIT ADVISOR	17085450	YES		6/30/2016
LATRISHIA SMITH	BENEFIT ADVISOR	17673917	YES		6/30/2016
SHANDREKA SMITH	BENEFIT ADVISOR	17658124	YES		6/30/2016
MARSHAY SPEAD	BENEFIT ADVISOR	17328295	YES		6/30/2016
JORDAN SPIVEY	BENEFIT ADVISOR	17658193	YES		6/30/2016

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