Notification of Changes for Business Entity
General Information
Business Entity Name:	SUPERIOR VISION BENEFIT MANAGEMENT, INC.
Incorporation / Formation Date:	1/5/1984
FEIN:	22-2512930
Ohio License Number:	40891
NPN:	4583032
DBA / Trade Name:
State of Domicile:	NJ
County:	MORRIS
Business Address
Address 1:	939 ELKRIDGE LANDING ROAD, SUITE 200
Address 2:
City:	LINTHICUM
State:	MD
Zip:	21090
Phone:	8002431401
Fax:
Business Web Site Address:
Business Email Address:	SPARKINSON@SUPERIORVISION.COM
Mailing Address
Address 1:	ATTN: SANDRA PARKINSON, COMPLIANCE MGR.
Address 2:	11090 WHITE ROCK ROAD, SUITE 175
City:	RANCHO CORDOVA
State:	CA
Zip:	95670
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

Submitted By
Submitted By:	GLEN MCDONALD
Title:	SR. VICE PRESIDENT OF OPERATIONS AND GENERAL MANAGER
Phone Number:	8009236766, EXT. 2254
Email Address:	GMCDONALD@SUPERIORVISION.COM