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
YANCY MARTINEZ	BENEFIT ADVISOR	17673934	YES		5/19/2016
DEBRA MATTHEWS	BENEFIT ADVISOR	17097695	YES		5/19/2016
SPARKLE MCCOY	BENEFIT ADVISOR	16961703	YES		5/19/2016
MONTE MCCUIN	BENEFIT ADVISOR	17613095	YES		5/19/2016
RICHARD MCCULLOUGH	BENEFIT ADVISOR	13080173	YES		5/19/2016
ZACHARY MCMILLIAN	BENEFIT ADVISOR	17703755	YES		5/19/2016
GABRIELLA MENDOZA	BENEFIT ADVISOR	17629945	YES		5/19/2016
WILLIAM MONTIEL	BENEFIT ADVISOR	17658044	YES		5/19/2016
CAROLYN MOWAN-VILLARREAL	BENEFIT ADVISOR	9286514	YES		5/19/2016
ANGELINNA MOWER	BENEFIT ADVISOR	17382978	YES		5/19/2016
DANDRA NEWMAN	BENEFIT ADVISOR	1288630	YES		5/19/2016
ANGELA OATES	BENEFIT ADVISOR	17335657	YES		5/19/2016
SANDRA OBI	BENEFIT ADVISOR	1908209	YES		5/19/2016
VIVIAN ORTIZ	BENEFIT ADVISOR	17072285	YES		5/19/2016
AVASHUN PACE	BENEFIT ADVISOR	17613099	YES		5/19/2016

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