Notification of Changes for Business Entity
General Information
Business Entity Name:	EXTEND INSURANCE SERVICES, LLC
Incorporation / Formation Date:
FEIN:	202487260
Ohio License Number:	32852
NPN:	8415824
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:	LAC@EXTENDHEALTH.COM
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
HESTER, TAWNIE	BENEFIT ADVISOR	17015412	YES		12/30/15
HICKS DAVIS, TONI	BENEFIT ADVISOR	17522711	YES		12/30/15
HILL, ALANA	BENEFIT ADVISOR	16735882	YES		12/30/15
HILL, CHRISTINA	BENEFIT ADVISOR	16746212	YES		12/30/15
HILL, RICCARDO	BENEFIT ADVISOR	17038066	YES		12/30/15
HILLARD, TERRY	BENEFIT ADVISOR	1153004	YES		12/30/15
HILLS, EMMA	BENEFIT ADVISOR	16693455	YES		12/30/15
HILLS, TRACY	BENEFIT ADVISOR	17318131	YES		12/30/15
HIMES, MALCOLM	BENEFIT ADVISOR	17710022	YES		12/30/15
HINES, RAJEEYAH	BENEFIT ADVISOR	17371941	YES		12/30/15
HIPPS, AUDREY	BENEFIT ADVISOR	17027541	YES		12/30/15
HODGE, ANGELA	BENEFIT ADVISOR	17051409	YES		12/30/15
HOFFMAN, PARKER	BENEFIT ADVISOR	17624702	YES		12/30/15
HOLDSWORTH, WAYNE	BENEFIT ADVISOR	16777996	YES		12/30/15
HOLLIS, DESHONE	BENEFIT ADVISOR	17344955	YES		12/30/15

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