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
LISA WATSON	BENEFIT ADVISOR	17692246	YES		6/30/2016
MURRIEL WATSON	BENEFIT ADVISOR	16569317	YES		6/30/2016
TIFFANY WATSON	BENEFIT ADVISOR	17328151	YES		6/30/2016
KELLY WEATHERS	BENEFIT ADVISOR	16234182	YES		6/30/2016
ALAN WEBB	BENEFIT ADVISOR	17630060	YES		6/30/2016
KASANDRA WHITE	BENEFIT ADVISOR	17683452	YES		6/30/2016
KRYSTAL WHITE	BENEFIT ADVISOR	17659715	YES		6/30/2016
CHANICE WICKS	BENEFIT ADVISOR	17658272	YES		6/30/2016
SHANIQUA WILLIAMS	BENEFIT ADVISOR	17673875	YES		6/30/2016
YVETTE WILLIAMS	BENEFIT ADVISOR	9726858	YES		6/30/2016
ELAINE WILLIS	BENEFIT ADVISOR	17120607	YES		6/30/2016
BRENDA WILSON	BENEFIT ADVISOR	17618759	YES		6/30/2016
MARION WILSON	BENEFIT ADVISOR	7315570	YES		6/30/2016
MAE WOODARD	BENEFIT ADVISOR	16499291	YES		6/30/2016
DAPHANIE WRIGHT	BENEFIT ADVISOR	17658281	YES		6/30/2016

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