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:	YES
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
GRAHAM, ROCKY	BENEFIT ADVISOR	17031947	YES		12/30/15
GREEN, LANITHA	BENEFIT ADVISOR	17073438	YES		12/30/15
GREEN, PHILIP	BENEFIT ADVISOR	17328382	YES		12/30/15
GREEN, RISE	BENEFIT ADVISOR	17349944	YES		12/30/15
GREEN, TARA	BENEFIT ADVISOR	17051401	YES		12/30/15
GREENSLADE, VICKI	BENEFIT ADVISOR	17640108	YES		12/30/15
GRICE, STEPHEN	BENEFIT ADVISOR	17692147	YES		12/30/15
GRIFFIN, JASON	BENEFIT ADVISOR	16995042	YES		12/30/15
GRIFFING, BARBARA	BENEFIT ADVISOR	17063266	YES		12/30/15
GRIFFITHS, JANIECE	BENEFIT ADVISOR	17689264	YES		12/30/15
GRIGGSBY, FRANCEE	BENEFIT ADVISOR	17328146	YES		12/30/15
GRIMES, LATONIE	BENEFIT ADVISOR	1321224	YES		12/30/15
GU, WEINING	BENEFIT ADVISOR	15746219	YES		12/30/15
GUTIERREZ, MARIA	BENEFIT ADVISOR	8982628	YES		12/30/15
GWILLIAM, RAY	BENEFIT ADVISOR	14862115	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