Notification of Changes for Business Entity
General Information
Business Entity Name:	EXCHANGE INSURANCE SERVICES, LLC
Incorporation / Formation Date:
FEIN:	202487160
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:
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
BAIRES, LAURA	BENEFIT ADVISOR	17332253	YES		12/22/15
BATIE, LISA	BENEFIT ADVISOR	17374351	YES		12/22/15
BAUGHMAN, TIMOTHY	BENEFIT ADVISOR	17408609	YES		12/22/15
BEARD, LA TONYA	BENEFIT ADVISOR	17658086	YES		12/22/15
BEARDEN, BRIAN	BENEFIT ADVISOR	1081349	YES		12/22/15
BEARDEN, FRANK	BENEFIT ADVISOR	16342498	YES		12/22/15
BEASLEY, ADRIENNE	BENEFIT ADVISOR	17332176	YES		12/22/15
BEASLEY, CHARLEENE	BENEFIT ADVISOR	17658295	YES		12/22/15
BEAUCHAMP, DAVID	BENEFIT ADVISOR	16799965	YES		12/22/15
BECKMANN, ANNMARIE	BENEFIT ADVISOR	17011069	YES		12/22/15
BELL, RICHARD	BENEFIT ADVISOR	11657084	YES		12/22/15
BELL, YONWI	BENEFIT ADVISOR	17080117	YES		12/22/15
BEMBENEK, FRAN	BENEFIT ADVISOR	17624577	YES		12/22/15
BEMENT, BOYD	BENEFIT ADVISOR	16727890	YES		12/22/15
BEMIS, MARLENE	BENEFIT ADVISOR	17059890	YES		12/22/15

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