Notification of Changes for Business Entity
General Information
Business Entity Name:	WELLS FARGO INSURANCE SERVICES USA, INC.
Incorporation / Formation Date:	07/08/1994
FEIN:	56-1882208
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	NC
County:	MECKLENBURG
Business Address
Address 1:	WELLS FARGO INSURANCE SERVICES USA, INC.
Address 2:	6100 FAIRVIEW ROAD SUITE 1400 D1067-140
City:	CHARLOTTE
State:	NC
Zip:	28210
Phone:	704-715-8133
Fax:	704-715-4002
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	WELLS FARGO INSURANCE SERVICES USA, INC.
Address 2:	6100 FAIRVIEW ROAD SUITE 1400 D1067-140
City:	CHARLOTTE
State:	NC
Zip:	28210
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
MICHELLE SHANER	AGENT	8755960		YES	12/29/2017

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)	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

Submitted By
Submitted By:	BRENDA CONNER
Title:	LICENSING COORDINATOR
Phone Number:	515-776-3816
Email Address:	BRENDA.CONNER@USI.COM