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:	801-415-0579
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
TASMINE SMITH	AGENT	17087092		YES	11/28/2016
MARSHAY SPEAD	AGENT	17328295		YES	11/28/2016
BRANDY TAYLOR ANDERSON	AGENT	18112095		YES	11/28/2016
ANTHONY TERRICE	AGENT	16998238		YES	11/28/2016
JOSEPHINE TRUEMAN	AGENT	17659714		YES	11/28/2016
DANNY TRUSSELL	AGENT	1303198		YES	11/28/2016
TOMMY TUCKER	AGENT	999413		YES	11/28/2016
KEOSHA VAUGHN	AGENT	17673774		YES	11/28/2016
ANDREA VILLANUEVA MOLINA	AGENT	17659695		YES	11/28/2016
QUANESHA WARD	AGENT	17658275		YES	11/28/2016
LASHUNDA WASHINGTON	AGENT	17692125		YES	11/28/2016
ERICA WATSON	AGENT	16546277		YES	11/28/2016
IRMA WHITE	AGENT	17673885		YES	11/28/2016
BOB WILKES	AGENT	5458556		YES	11/28/2016
MARION WILSON	AGENT	7315570		YES	11/28/2016

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