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
AQUEELAH ABDULLAH	AGENT	18082241		YES	12/28/2016
MUHAMMAD ABEDIN	AGENT	17658273		YES	12/28/2016
MAUREEN AHERN	AGENT	17597823		YES	12/28/2016
SOPHIA ALEXANDER	AGENT	17114575		YES	12/28/2016
KESHOWNA ALLEN	AGENT	17370572		YES	12/28/2016
MICKI ALLEN	AGENT	17113765		YES	12/28/2016
REBEKAH ALLEN	AGENT	16730566		YES	12/28/2016
KARIMI ALONZO	AGENT	18066415		YES	12/28/2016
DULCE AMAYA MERAZ	AGENT	18030311		YES	12/28/2016
AMANDRA ANDERSON	AGENT	18048305		YES	12/28/2016
BRIAN ANDERSON	AGENT	1249591		YES	12/28/2016
NIKITA ANDERSON	AGENT	17655177		YES	12/28/2016
MELODY ANDREWS	AGENT	17749819		YES	12/28/2016
ELICIA ARCHIBALD	AGENT	18030236		YES	12/28/2016
LUIS AROCHO	AGENT	17085401		YES	12/28/2016

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:	801-415-0579
Email Address:	LAC@EXTENDHEALTH.COM