Notification of Changes for Business Entity
General Information
Business Entity Name:	EXTEND INSURANCE SERVICES
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
MONICA BEATRICE	AGENT	18009249	YES		09/22/2016
MICHAEL BEKELE	AGENT	18034894	YES		09/22/2016
MADARIAH BELL	AGENT	18084057	YES		09/22/2016
CYLINTHIA BIRDOW	AGENT	18088528	YES		09/22/2016
BRANDON BLACKMORE	AGENT	18088531	YES		09/22/2016
RACHEL BLYTHE	AGENT	18084008	YES		09/22/2016
DARLENE BOCLAIR	AGENT	5031724	YES		09/22/2016
FELICIA BOGGESS	AGENT	18048366	YES		09/22/2016
TAMARA BONNER	AGENT	18035003	YES		09/22/2016
JASMINE BOYD	AGENT	18082207	YES		09/22/2016
TAMMY BROCKINTON	AGENT	18048379	YES		09/22/2016
CHARLES BROOKS	AGENT	18082234	YES		09/22/2016
MICHAEL BROWN	AGENT	18066432	YES		09/22/2016
ZEE-DONNA BROWN	AGENT	17703822	YES		09/22/2016
STEPHEN BROWNE	AGENT	14657124	YES		09/22/2016

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