Notification of Changes for Business Entity
General Information
Business Entity Name:	EXCHANGE 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:	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:
Mailing Address
Address 1:	19075 STERLING VIEW DRIVE
Address 2:	SUITE A-1
City:	SOUTH JORDAN
State:	UT
Zip:	84095
Indicate the type of change you are seeking
Address Change:	YES
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
ABBOTT, JULIA	BENEFIT ADVISOR	14862280	YES		12/22/15
ABEBE, MESERET	BENEFIT ADVISOR	16746222	YES		12/22/15
ABRAHAM, TAMEKA	BENEFIT ADVISOR	17658138	YES		12/22/15
ADAIR, RASHIDA	BENEFIT ADVISOR	17378580	YES		12/22/15
ADJOBI, ALESHIA	BENEFIT ADVISOR	16795885	YES		12/22/15
ADU-GYAMFI, DAN	BENEFIT ADVISOR	17624620	YES		12/22/15
ADUNDO, LENNOX	BENEFIT ADVISOR	16717666	YES		12/22/15
AHMAD, TISHA	BENEFIT ADVISOR	16364433	YES		12/22/15
AHMED, MUSHTAQ	BENEFIT ADVISOR	8228168	YES		12/22/15
AKPAN, CRYSTAL	BENEFIT ADVISOR	17589052	YES		12/22/15
AKPOGUMA, MICHAEL	BENEFIT ADVISOR	17658132	YES		12/22/15
ALDAPE, BRIDGET	BENEFIT ADVISOR	16369573	YES		12/22/15
ALEX, ALEXIS	BENEFIT ADVISOR	17708059	YES		12/22/15
ALEXANDER, JAMES	BENEFIT ADVISOR	17360899	YES		12/22/15
ALEXANDER, MITCHELL	BENEFIT ADVISOR	17667843	YES		12/22/15

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:	801-415-0579
Email Address:	LAC@EXTENDHEALTH.COM