Notification of Changes for Business Entity
General Information
Business Entity Name:	DELTA DENTAL PLAN OF MICHIGAN, INC.
Incorporation / Formation Date:
FEIN:	38-1791480
Ohio License Number:	12618
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	US
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:
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:	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:	DENISE A. CHADWELL
Title:	RISK MANAGEMENT & COMPLIANCE SPECIALIST
Phone Number:	517-347-5258
Email Address:	COMPLIANCE@DELTADENTALMI.COM