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:
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:	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
BUCAO, ANN THERESA	BENEFIT ADVISOR	16715049	YES		12/22/15
BULLA, VIVIANA	BENEFIT ADVISOR	17673193	YES		12/22/15
BULLARD, MARLENE	BENEFIT ADVISOR	15837468	YES		12/22/15
BURGESS, ALLEN	BENEFIT ADVISOR	34942	YES		12/22/15
BURKE, EPHRAIM	BENEFIT ADVISOR	15888469	YES		12/22/15
BURNS, JAHN	BENEFIT ADVISOR	17029999	YES		12/22/15
BURT, LAUREN	BENEFIT ADVISOR	17584858	YES		12/22/15
BURT, MARK	BENEFIT ADVISOR	17059281	YES		12/22/15
BURTON, KAREN	BENEFIT ADVISOR	17053649	YES		12/22/15
BURTON, TAMIKA	BENEFIT ADVISOR	15972321	YES		12/22/15
BURTON, TINA	BENEFIT ADVISOR	15919577	YES		12/22/15
BUSBY, TONYA	BENEFIT ADVISOR	17059352	YES		12/22/15
BUSS, SUZANNE	BENEFIT ADVISOR	17071169	YES		12/22/15
BUTENHOFF, KELLY	BENEFIT ADVISOR	17074575	YES		12/22/15
BUTLER, STEPHAN	BENEFIT ADVISOR	7834117	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:	8014150579
Email Address:	LAC@EXTENDHEALTH.COM