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 DRIVE, 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 DRIVE, 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
LANEISA JACKSON	AGENT	246739		YES	10/25/2016
BRITTANY JOHNSON	AGENT	17624691		YES	10/25/2016
JONNAE JONES	AGENT	17694700		YES	10/25/2016
ERIN JUDD	AGENT	18028008		YES	10/25/2016
SASHA KABARTAY	AGENT	18095162		YES	10/25/2016
SHEMEKA KENNEYBREW	AGENT	17710937		YES	10/25/2016
TAMARA KNIGHT TRIGG	AGENT	18088574		YES	10/25/2016
LISA LAFFITY	AGENT	18103660		YES	10/25/2016
JESSICA LOGAN	AGENT	17332412		YES	10/25/2016
WILLIAM MANOR	AGENT	7684857		YES	10/25/2016
ZACHARY MCMILLIAN	AGENT	17703755		YES	10/25/2016
GLORIA MIDDLETON	AGENT	17335712		YES	10/25/2016
MONIQUE MORENO	AGENT	18048368		YES	10/25/2016
KEIUNTE MORGAN	AGENT	17029916		YES	10/25/2016
ANGELINNA MOWER	AGENT	17382978		YES	10/25/2016

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