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
JANETTE OROZCO	BENEFIT ADVISOR	17584823		YES	5/20/2016
OLUBUKOLA OSHOGBE	BENEFIT ADVISOR	17608338		YES	5/20/2016
JESSE OWENS	BENEFIT ADVISOR	17658207		YES	5/20/2016
GABRIELLE PATTERSON	BENEFIT ADVISOR	16850417		YES	5/20/2016
DIANNE PERKINS	BENEFIT ADVISOR	17015585		YES	5/20/2016
BELINDA PERSON	BENEFIT ADVISOR	17050402		YES	5/20/2016
WAYNE PETERS	BENEFIT ADVISOR	17376755		YES	5/20/2016
ELOISA PETERSON	BENEFIT ADVISOR	17037003		YES	5/20/2016
WINFORT PHYNES	BENEFIT ADVISOR	17344976		YES	5/20/2016
BRITTANY PONIUS	BENEFIT ADVISOR	17393303		YES	5/20/2016
SHE'AMERIOUS POPE	BENEFIT ADVISOR	17673874		YES	5/20/2016
JAZMINE PORTER	BENEFIT ADVISOR	17035972		YES	5/20/2016
KASANDRA POWELL	BENEFIT ADVISOR	15920405		YES	5/20/2016
TINA PRICE	BENEFIT ADVISOR	15959306		YES	5/20/2016
RODRICK RANDALL	BENEFIT ADVISOR	16779254		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