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:	19075 STERLING VIEW DRIVE
Address 2:	SUITE A-1
City:	SOUTH JORDAN
State:	UT
Zip:	84095
Phone:	8014150579
Fax:
Business Web Site Address:
Business Email Address:	LAC@EXTENDHEALTH.COM
Mailing Address
Address 1:	19075 STERLING VIEW DRIVE
Address 2:	SUITE A-1
City:	SOUTH JORDAN
State:	UT
Zip:	84
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
MEEDER, ROBERT	BENEFIT ADVISOR	16129536	YES		12/30/15
MEINERS, JESSICA	BENEFIT ADVISOR	17673206	YES		12/30/15
MELLOTT, BRANDY	BENEFIT ADVISOR	17673836	YES		12/30/15
MENDENHALL, CHRISTINE	BENEFIT ADVISOR	17698683	YES		12/30/15
MENESES, CAROLINA	BENEFIT ADVISOR	17349877	YES		12/30/15
MENNA, JESSICA	BENEFIT ADVISOR	17665344	YES		12/30/15
MENSAH PARNELL, JODY	BENEFIT ADVISOR	17521603	YES		12/30/15
MERCER, CLYDE	BENEFIT ADVISOR	17484627	YES		12/30/15
METCALF, ROGER	BENEFIT ADVISOR	2770644	YES		12/30/15
MICHAEL, FRANK	BENEFIT ADVISOR	14656805	YES		12/30/15
MICHAL, ASHLEY	BENEFIT ADVISOR	17716836	YES		12/30/15
MILES, CHRISTOPHER	BENEFIT ADVISOR	16766687	YES		12/30/15
MILES, KENNETH	BENEFIT ADVISOR	17039652	YES		12/30/15
MILLER, LATOYA	BENEFIT ADVISOR	17670562	YES		12/30/15
MILLER, NANCY	BENEFIT ADVISOR	17705225	YES		12/30/15

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