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
BRANDON HOUSE	AGENT	17655125	YES		8/15/2016
BETH JACINTHO	AGENT	17047280	YES		8/15/2016
ALBERT JANEZIC	AGENT	3181889	YES		8/15/2016
GLORIA JONES	AGENT	1269484	YES		8/15/2016
CLARENCE KNIGHT	AGENT	16901661	YES		8/15/2016
MICHAEL KNOWLES	AGENT	15000139	YES		8/15/2016
REKKIAH LOUDEN	AGENT	17555508	YES		8/15/2016
BRIANNA MAY	AGENT	17665345	YES		8/15/2016
RICHARD MCAFFEE	AGENT	15000158	YES		8/15/2016
JEAN MCINTOSH	AGENT	17063220	YES		8/15/2016
CHENETTA MCRAE EBE	AGENT	17641009	YES		8/15/2016
JESSICA MEINERS	AGENT	17673206	YES		8/15/2016
SHIRLEY MOORE	AGENT	17085478	YES		8/15/2016
ANTWANETTA MORRISON	AGENT	17358736	YES		8/15/2016
BERNARD MURRELL	AGENT	17092940	YES		8/15/2016

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