Notification of Changes for Business Entity
General Information
Business Entity Name:	SUPERIOR VISION SERVICES, INC
Incorporation / Formation Date:
FEIN:	13-3741352
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	DE
County:	NEW CASTLE
Business Address
Address 1:	11090 WHITE ROCK ROAD, SUITE 175
Address 2:
City:	RANCHO CORDOVA
State:	CA
Zip:	95670
Phone:	800 923-6766
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	11090 WHITE ROCK ROAD, SUITE 175
Address 2:
City:	RANCHO CORDOVA
State:	CA
Zip:	95670
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

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
MICHAEL BOXER	DIRECTOR	522-66-2882		YES	10/19/2018

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:	BRUCE TAVEL
Title:	SENIOR VICE PRESIDENT & SECRETARY
Phone Number:	410 595-7110
Email Address:	BRUCE.TAVEL@VERSANTHEALTH.COM