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
JESSICA MARION	AGENT	17624658		YES	12/29/2016
GLENDA MARTINEZ	AGENT	17091628		YES	12/29/2016
RICARDO MARTINEZ	AGENT	15946809		YES	12/29/2016
WENDY MARTINEZ	AGENT	18048299		YES	12/29/2016
YANCY MARTINEZ VELAZQUEZ	AGENT	17673934		YES	12/29/2016
JENNIFER MATSUNANGA	AGENT	17048219		YES	12/29/2016
SHAMIA MAYS	AGENT	17679207		YES	12/29/2016
MONTE MCCUIN	AGENT	17613095		YES	12/29/2016
DOMINIC MCCULLOUGH	AGENT	17715489		YES	12/29/2016
BARBARA MCGEE-TURNER	AGENT	16846162		YES	12/29/2016
CAROLYN MCGRIFF	AGENT	17029970		YES	12/29/2016
JEAN MCINTOSH	AGENT	17063220		YES	12/29/2016
JAMES MCKINLEY	AGENT	1093366		YES	12/29/2016
KACY MCNAIR	AGENT	18095130		YES	12/29/2016
JESSICA MEINERS	AGENT	17673206		YES	12/29/2016

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:	801-415-0579
Email Address:	LAC@EXTENDHEALTH.COM