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
WASHINGTON, CHAMARRA	BENEFIT ADVISOR	17328436	YES		12/31/15
WASHINGTON, HERBERT	BENEFIT ADVISOR	16728421	YES		12/31/15
WASHINGTON, TAMMIE	BENEFIT ADVISOR	16715671	YES		12/31/15
WASHINGTON, TIFFANY	BENEFIT ADVISOR	17375446	YES		12/31/15
WASHOM, LINDA	BENEFIT ADVISOR	17040922	YES		12/31/15
WATKINS, TAMARA	BENEFIT ADVISOR	17641190	YES		12/31/15
WATSON, ERICA	BENEFIT ADVISOR	16546277	YES		12/31/15
WATSON, GLENN	BENEFIT ADVISOR	17672007	YES		12/31/15
WATSON, LISA	BENEFIT ADVISOR	17692246	YES		12/31/15
WATSON, MURRIEL	BENEFIT ADVISOR	16569317	YES		12/31/15
WEBB, JACQUELINE	BENEFIT ADVISOR	16756492	YES		12/31/15
WEBB, LINDA	BENEFIT ADVISOR	16306506	YES		12/31/15
WEBER, NAKESHA	BENEFIT ADVISOR	17689306	YES		12/31/15
WEBSTER, RONALD	BENEFIT ADVISOR	15993540	YES		12/31/15
WEEKS, JAMES	BENEFIT ADVISOR	16324260	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