Notification of Changes for Business Entity
General Information
Business Entity Name:	GREEN TREE INSURANCE AGENCY
Incorporation / Formation Date:
FEIN:	411254595
Ohio License Number:	23336
NPN:	49357
DBA / Trade Name:
State of Domicile:	MN
County:	HENNEPIN
Business Address
Address 1:	345 ST PETER ST
Address 2:
City:	ST PAUL
State:	MN
Zip:	55102
Phone:	8667406327
Fax:	6053557203
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1400 TURBINE DR R202
Address 2:
City:	RAPID CITY
State:	SD
Zip:	57703
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
DAWN DANKO	PRODUCER	18211059	YES		05102017

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:	SUSAN ABLER-GREGG
Title:	LICENSING COORDINATOR
Phone Number:	6053557000
Email Address:	SUSAN.ABLER-GREGG@GTINSURANCEAGENCY.COM