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:	8014150579
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
CARROLL CLARK	AGENT	8447556	YES		8/21/2018
NICOLE DELERME	AGENT	18575559	YES		8/21/2018
ARICKA CHURCHILL	AGENT	18816543	YES		8/21/2018
DILLON BURRAGE	AGENT	18841353	YES		8/21/2018
LAKEISHA STEWART	AGENT	18092970	YES		8/21/2018
COLLEEN CORRIGAN-QUIRK	AGENT	2167962	YES		8/21/2018
MICHAEL DANOVICH	AGENT	18706810	YES		8/21/2018
JANICE CHRISTIAN	AGENT	18666671	YES		8/21/2018
ELIZABETH DESMARAIS	AGENT	6963053	YES		8/21/2018
MARIA GARCIA	AGENT	17379811	YES		8/21/2018
KISHA JONES	AGENT	17017224	YES		8/21/2018
KHALILAH BROWN	AGENT	17673795	YES		8/21/2018

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
DAVID FEIL

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:	18014150579
Email Address:	LAC@WILLISTOWERSWATSON.COM