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
MICHAEL BARLOW	AGENT	11179114		YES	3/30/2017
AMY BOSWELL	AGENT	17021113		YES	3/30/2017
DEVIN CLARKSON	AGENT	17063281		YES	3/30/2017
CATINA CONLEY	AGENT	17048287		YES	3/30/2017
DONNA DOWNING	AGENT	1304219		YES	3/30/2017
KATHY GENTLE	AGENT	17360825		YES	3/30/2017
LIZETH HERNANDEZ	AGENT	18069920		YES	3/30/2017
DIAMOND HICKS	AGENT	18112068		YES	3/30/2017
MICHELLE LOVELESS	AGENT	17305110		YES	3/30/2017
MARCUS MARTIN	AGENT	16333016		YES	3/30/2017
ROSLYN MCKINNEY	AGENT	17689210		YES	3/30/2017
JAMES MEEDER	AGENT	16294150		YES	3/30/2017
ASHLEY MICHAL	AGENT	17716836		YES	3/30/2017
STANLEY NOVAK	AGENT	16304847		YES	3/30/2017
ANGELIQUE RODRIGUEZ	AGENT	14448760		YES	3/30/2017

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