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
MALCOLM MASTELLER	BENEFIT ADVISOR	5461262		YES	5/20/2016
RICHARD MCAFFEE	BENEFIT ADVISOR	15000158		YES	5/20/2016
DOMINIC MCCULLOUGH	BENEFIT ADVISOR	17715489		YES	5/20/2016
CAROLYN MCGRIFF	BENEFIT ADVISOR	17029970		YES	5/20/2016
JEAN MCINTOSH	BENEFIT ADVISOR	17063220		YES	5/20/2016
LORETTA MCKENZIE	BENEFIT ADVISOR	17344860		YES	5/20/2016
LECOUNT MCLAUGHLIN	BENEFIT ADVISOR	1310879		YES	5/20/2016
JESSICA MEINERS	BENEFIT ADVISOR	17673206		YES	5/20/2016
BRANDY MELLOTT	BENEFIT ADVISOR	17673836		YES	5/20/2016
JODY MENSAH PARNELL	BENEFIT ADVISOR	17521603		YES	5/20/2016
ASHLEY MICHAL	BENEFIT ADVISOR	17716836		YES	5/20/2016
HERBERT MILLINER	BENEFIT ADVISOR	689244		YES	5/20/2016
MICHAEL MILLS	BENEFIT ADVISOR	17658099		YES	5/20/2016
SHIRLEY MOORE	BENEFIT ADVISOR	17085478		YES	5/20/2016
OLGA MORA	BENEFIT ADVISOR	2971853		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