Notification of Changes for Business Entity
General Information
Business Entity Name:	GREEN TREE INSURANCE AGENCY, INC.
Incorporation / Formation Date:	10/01/1975
FEIN:	411254595
Ohio License Number:	23336
NPN:
DBA / Trade Name:
State of Domicile:	MN
County:	RAMSEY
Business Address
Address 1:	345 ST PETER ST L11A
Address 2:
City:	ST PAUL
State:	MN
Zip:	55102
Phone:	8004239527
Fax:	6053557203
Business Web Site Address:
Business Email Address:	HEATHER.CRAWFORD@GT-CS.COM
Mailing Address
Address 1:	345 ST PETER ST L11A
Address 2:
City:	ST PAUL
State:	MN
Zip:	55102
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

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
JAKE SASSE	SALES	1074130		YES	6/25/2016

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:	HEATHER CRAWFORD
Title:	SEN. LICENSING COORDINATOR
Phone Number:	8004239527
Email Address:	HEATHER.CRAWFORD@GT-CS.COM