Notification of Changes for Business Entity
General Information
Business Entity Name:	EXTEND INSURANCE SERVICES, LLC
Incorporation / Formation Date:
FEIN:	202487260
Ohio License Number:	32852
NPN:	8415824
DBA / Trade Name:
State of Domicile:	UT
County:	SALT LAKE
Business Address
Address 1:	10975 S. STERLING VIEW DRIVE
Address 2:
City:	SOUTH JORDAN
State:	UT
Zip:	84095
Phone:	8014150579
Fax:
Business Web Site Address:
Business Email Address:	LAC@EXTENDHEALTH.COM
Mailing Address
Address 1:	10975 S. STERLING VIEW DRIVE
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
PRETTY, MICHELLE	BENEFIT ADVISOR	11557582		YES	12/31/15
PROPSON, KATE	BENEFIT ADVISOR	11606073		YES	12/31/15
PRUITT, AIDA	BENEFIT ADVISOR	11557578		YES	12/31/15
PUCHALSKI, JODI LYN	BENEFIT ADVISOR	11565991		YES	12/31/15
RANALLI, JOHN	BENEFIT ADVISOR	11478957		YES	12/31/15
RAND, KEVIN	BENEFIT ADVISOR	11867980		YES	12/31/15
RANKIN, GERALD	BENEFIT ADVISOR	11602722		YES	12/31/15
RAYMOND, ANDREA	BENEFIT ADVISOR	11586658		YES	12/31/15
REILLY, MARK	BENEFIT ADVISOR	2630012		YES	12/31/15
REYNOSO, JESUS	BENEFIT ADVISOR	11550413		YES	12/31/15
RIDDLE, DEREK	BENEFIT ADVISOR	8851553		YES	12/31/15
ROBLEDO, SAMUEL	BENEFIT ADVISOR	1267104		YES	12/31/15
ROSECKE, LESLIE	BENEFIT ADVISOR	6943954		YES	12/31/15
ROSS, OLIVIA	BENEFIT ADVISOR	8818260		YES	12/31/15
RUDNITSKY, BARRY	BENEFIT ADVISOR	6932351		YES	12/31/15

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 AND CHIEF TECHNOLOGY OFFICER
Phone Number:	8014150579
Email Address:	LAC@EXTENDHEALTH.COM