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
JULIA ABBOTT	BENEFIT ADVISOR	14862280		YES	5/20/2016
TAMEKA ABRAHAM	BENEFIT ADVISOR	17658138		YES	5/20/2016
RASHIDA ADAIR	BENEFIT ADVISOR	17378580		YES	5/20/2016
DAN ADU-GYAMFI	BENEFIT ADVISOR	17624620		YES	5/20/2016
CRYSTAL AKPAN	BENEFIT ADVISOR	17589052		YES	5/20/2016
MICHAEL AKPOGUMA	BENEFIT ADVISOR	17658132		YES	5/20/2016
STEFFINE AMODT	BENEFIT ADVISOR	17709008		YES	5/20/2016
CHRISTOPHER ARTHUR	BENEFIT ADVISOR	17063268		YES	5/20/2016
CHRISTINA ASH	BENEFIT ADVISOR	16779239		YES	5/20/2016
MARYANN ASHBRUN	BENEFIT ADVISOR	17659674		YES	5/20/2016
RICHARD BARRETT	BENEFIT ADVISOR	17085409		YES	5/20/2016
CHARLEENE BEASLEY	BENEFIT ADVISOR	17658295		YES	5/20/2016
KATINA BENNETT	BENEFIT ADVISOR	17673843		YES	5/20/2016
STEVEN BIASATTI	BENEFIT ADVISOR	14910480		YES	5/20/2016
ROBERT BISHOP	BENEFIT ADVISOR	17665411		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