Notification of Changes for Business Entity
General Information
Business Entity Name:	BENEFIT BUILDERS INC
Incorporation / Formation Date:
FEIN:	311483106
Ohio License Number:	10968
NPN:	2226016
DBA / Trade Name:
State of Domicile:	OH
County:	MONTGOMERY
Business Address
Address 1:	7777 WASHINGTON VILLAGE DRIVE
Address 2:	SUITE 170
City:	DAYTON
State:	OH
Zip:	45459
Phone:	9374347887
Fax:	9374392905
Business Web Site Address:	WWW.BENEFITBUILDERS.NET
Business Email Address:	HMCELDERRY@BENEFITBUILDERS.NET
Mailing Address
Address 1:	7777 WASHINGTON VILLAGE DRIVE
Address 2:	SUITE 170
City:	DAYTON
State:	OH
Zip:	45459
Indicate the type of change you are seeking
Address Change:	YES
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

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

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