Notification of Changes for Business Entity
General Information
Business Entity Name:	GOLDENCARE USA, INC.
Incorporation / Formation Date:
FEIN:	411386011
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	MN
County:	HENNEPIN
Business Address
Address 1:	10700 OLD COUNTY ROAD 15 STE 450
Address 2:
City:	PLYMOUTH
State:	MN
Zip:	55441
Phone:	800-842-7799
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	10700 OLD COUNTY ROAD 15 STE 450
Address 2:
City:	PLYMOUTH
State:	MN
Zip:	55441
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
STEVEN LOVELESS	AGENT	7153646	YES		12/05/17
JEFFREY LUND	AGENT	1564702	YES		12/05/17
MOHAMED MAKAREM	AGENT	238173	YES		12/05/17
KIMBERLY NORD-NASH	AGENT	17741608	YES		12/05/17
THOMAS PETERSON	AGENT	6927716	YES		12/05/17
WAYNE SAFRANSKI	AGENT	16145988	YES		12/05/17
ANTHONY SCHILLER	AGENT	15669903	YES		12/05/17
ROBERT SCHULTZ	AGENT	6949655	YES		12/05/17
STEVEN SCHWITZ	AGENT	779020	YES		12/05/17
BRIAN STAHL	AGENT	6271498	YES		12/05/17
HARRY STILLWELL	AGENT	7532258	YES		12/05/17
RONALD STOLLER	AGENT	2160784	YES		12/05/17
DAVID STONER	AGENT	10403089	YES		12/05/17
STEPHANIE WEYHRAUCH	AGENT	12462026	YES		12/05/17
KENNETH SILVER	AGENT	6944230	YES		12/05/17

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:	LEONARD ANDERSON
Title:	PRESIDENT
Phone Number:	800-842-7799
Email Address:	LGA@GOLDENCAREUSA.COM