| Notification of Changes for Business Entity |
| General Information | |
| Business Entity Name: | DELTA DENTAL PLAN OF MICHIGAN, INC. |
| Incorporation / Formation Date: | 10/22/1957 |
| FEIN: | 38-1791480 |
| Ohio License Number: | 12618 |
| NPN: | |
| DBA / Trade Name: | |
| State of Domicile: | MI |
| County: | INGHAM |
| Business Address | |
| Address 1: | 4100 OKEMOS RD. |
| Address 2: | |
| City: | OKEMOS |
| State: | MI |
| Zip: | 48864 |
| Phone: | 517-349-6000 |
| Fax: | 517-381-5671 |
| Business Web Site Address: | WWW.DELTADENTALOH.COM |
| Business Email Address: | COMPLIANCE@DELTADENTALMI.COM |
| Mailing Address | |
| Address 1: | P.O. BOX 30416 |
| Address 2: | |
| City: | LANSING |
| State: | MI |
| Zip: | 48909 |
| | |
| 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 |
| | |
| 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) | NO |
| 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? | NO |
| 3. If the answer to questions #1 or #2 is yes, identify the business or profession and the nature of person's involvement | |