Notification of Changes for Business Entity
General Information
Business Entity Name:	EXTEND INSURANCE SERVICES, LLC
Incorporation / Formation Date:
FEIN:	202487260
Ohio License Number:	32852
NPN:	8415824
DBA / Trade Name:
State of Domicile:	UT
County:	SALT LAKE
Business Address
Address 1:	10975 S. STERLING VIEW DRIVE
Address 2:
City:	SOUTH JORDAN
State:	UT
Zip:	84095
Phone:	8014150579
Fax:
Business Web Site Address:
Business Email Address:	LAC@EXTENDHEALTH.COM
Mailing Address
Address 1:	10975 S. STERLING VIEW DRIVE
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
MCDONALD, THOMAS	BENEFIT ADVISOR	8668338		YES	12/31/15
MCDONELL-ZINNERMAN, MARY	BENEFIT ADVISOR	11602724		YES	12/31/15
MENSSEN, SVEN	BENEFIT ADVISOR	5462770		YES	12/31/15
MILES, GEORGE	BENEFIT ADVISOR	11608559		YES	12/31/15
NARAJOWSKI, HENRY	BENEFIT ADVISOR	2882629		YES	12/31/15
NATIONS, JOHN	BENEFIT ADVISOR	1161869		YES	12/31/15
NORTHERN, PRECIOUS	BENEFIT ADVISOR	8872107		YES	12/31/15
AQUINO, SONIA	BENEFIT ADVISOR	14341763		YES	12/31/15
PAPA, ELIZABETH	BENEFIT ADVISOR	8998003		YES	12/31/15
PARADA, LAURA	BENEFIT ADVISOR	11030501		YES	12/31/15
PARRA, LAURA	BENEFIT ADVISOR	1114402		YES	12/31/15
PERLAKI, ADAM	BENEFIT ADVISOR	11566001		YES	12/31/15
PETROSKI, SHARON	BENEFIT ADVISOR	11586663		YES	12/31/15
PICKETT, MATINA	BENEFIT ADVISOR	11423054		YES	12/31/15
PLACENCIA, JUAN	BENEFIT ADVISOR	11576652		YES	12/31/15

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