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 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
JAZMIN SEALS	BENEFIT ADVISOR	16801835		YES	5/20/2016
SYED SHAH	BENEFIT ADVISOR	17692164		YES	5/20/2016
SHADMAN SHARIF	BENEFIT ADVISOR	17659640		YES	5/20/2016
CARLONDA SMITH	BENEFIT ADVISOR	17624723		YES	5/20/2016
LATRISHIA SMITH	BENEFIT ADVISOR	17673917		YES	5/20/2016
TASMINE SMITH	BENEFIT ADVISOR	17087092		YES	5/20/2016
CESAR SOTELO	BENEFIT ADVISOR	17063248		YES	5/20/2016
MARSHAY SPEAD	BENEFIT ADVISOR	17328295		YES	5/20/2016
ERIC STANDER	BENEFIT ADVISOR	17604530		YES	5/20/2016
JOVONDA STARLING	BENEFIT ADVISOR	17036023		YES	5/20/2016
CAROLYNE TANUI	BENEFIT ADVISOR	17702762		YES	5/20/2016
CHELSEY TERRY	BENEFIT ADVISOR	17673922		YES	5/20/2016
JAMES THELEN	BENEFIT ADVISOR	17658137		YES	5/20/2016
STEPHANIE TIMON	BENEFIT ADVISOR	17659700		YES	5/20/2016
ARVONNA TURNER	BENEFIT ADVISOR	1011486		YES	5/20/2016

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