Notification of Changes for Business Entity
General Information
Business Entity Name:	CUSTOM BENEFIT PLANS
Incorporation / Formation Date:
FEIN:	232942938
Ohio License Number:	28754
NPN:	2007759
DBA / Trade Name:
State of Domicile:	PA
County:	MONTGOMERY
Business Address
Address 1:	616 EASTON ROAD
Address 2:
City:	WILLIOW GROVE
State:	PA
Zip:	19090
Phone:	866-422-9188 EXT.236
Fax:
Business Web Site Address:
Business Email Address:	DANA@CUSTOMBENEFITPLANS.COM
Mailing Address
Address 1:	PO BOX 499
Address 2:
City:	WILLOW GROVE
State:	PA
Zip:	19090
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
JOHN RUBERTO	PRESIDENT	2827134	YES

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:	SAL DINARDO
Title:	PRINCIPAL
Phone Number:	866-422-9188 EXT. 236
Email Address:	DANA@CUSTOMBENEFITPLANS.COM