Notification of Changes for Business Entity
General Information
Business Entity Name:	CAPACITY BENEFITS GROUP INC.
Incorporation / Formation Date:	10/07/1997
FEIN:	22-3335537
Ohio License Number:	3888
NPN:	2002111
DBA / Trade Name:
State of Domicile:	NJ
County:	BERGEN
Business Address
Address 1:	1 BLUE HILL PLAZA
Address 2:	P.O. BOX 1689
City:	PEARL RIVER
State:	NY
Zip:	10965
Phone:	2016612348
Fax:	20
Business Web Site Address:
Business Email Address:	CSALLAY@CAPCOVERAGE.COM
Mailing Address
Address 1:	1 BLUE HILL PLAZA
Address 2:	P.O. BOX 1689
City:	PEARL RIVER
State:	NY
Zip:	10965
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:	CYNTHIA SALLAY
Title:	CORPORATE COMPLIANCE ADMINISTRATOR
Phone Number:	2016612348
Email Address:	CSALLAY@CAPCOVERAGE.COM