Notification of Changes for Business Entity
General Information
Business Entity Name:	EXCHANGE 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:	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:	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
CONLEY, CATINA	BENEFIT ADVISOR	17048287	YES		12/29/15
CONTRERAS, BONNY	BENEFIT ADVISOR	17171622	YES		12/29/15
COOK, DENNIS	BENEFIT ADVISOR	6228377	YES		12/29/15
COOK, GAYLE	BENEFIT ADVISOR	1118269	YES		12/29/15
COOK, RAINY	BENEFIT ADVISOR	17329157	YES		12/29/15
COON, ROBERT	BENEFIT ADVISOR	15944889	YES		12/29/15
COOPER, PAULA	BENEFIT ADVISOR	17199865	YES		12/29/15
COOPER, TAMARA	BENEFIT ADVISOR	16766776	YES		12/29/15
COREY, SANDRA	BENEFIT ADVISOR	17085394	YES		12/29/15
COWAN, DAVID	BENEFIT ADVISOR	16184469	YES		12/29/15
COWAN, MARIE	BENEFIT ADVISOR	15874423	YES		12/29/15
COWLES, PAUL	BENEFIT ADVISOR	15889842	YES		12/29/15
CRAWFORD, KERRY	BENEFIT ADVISOR	16927263	YES		12/29/15
CREAR, CHADSITY	BENEFIT ADVISOR	17589083	YES		12/29/15
CRISPELL, TIMOTHY	BENEFIT ADVISOR	17126346	YES		12/29/15

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