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
EDWARD DELAHUNTY	AGENT	17363522	YES		08/08/2016
DONNA DOWNING	AGENT	1304219	YES		08/08/2016
HEIDI DUKE	AGENT	17002094	YES		08/08/2016
LAWRENCE ESSEL	AGENT	17349814	YES		08/08/2016
SHEILA FLAX	AGENT	16955870	YES		08/08/2016
MARY FOSTER	AGENT	17332173	YES		08/08/2016
GARY GARDNER	AGENT	13708537	YES		08/08/2016
BARBARA GARY	AGENT	17328207	YES		08/08/2016
JAMES GRAY	AGENT	16909820	YES		08/08/2016
STEPHEN GRICE	AGENT	17692147	YES		08/08/2016
DEBORAH HAMBELTON	AGENT	16127925	YES		08/08/2016
BRITTNEY HAMILTON	AGENT	17266841	YES		08/08/2016
EVERARDO HERNANDEZ RAMIREZ	AGENT	17692223	YES		08/08/2016
BRITTANI HILL	AGENT	17440985	YES		08/08/2016
SHYKENDRA HOLLOWAY	AGENT	17608321	YES		08/08/2016

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