Notification of Changes for Business Entity
General Information
Business Entity Name:	WELLS FARGO INSURANCE, INC.
Incorporation / Formation Date:
FEIN:	410587845
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	MN
County:	HENNEPIN
Business Address
Address 1:	600 HIGHWAY 169 S
Address 2:	SUITE 1200
City:	SAINT LOUIS PARK
State:	MN
Zip:	55426
Phone:	6126675595
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	600 HIGHWAY 169 S
Address 2:	SUITE 1200
City:	SAINT LOUIS PARK
State:	MN
Zip:	55426
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
MATHEW TOLCHINER	PRODUCER	17212606		YES	04/01/2016

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:	JACOB WYFFELS
Title:	LICENSING COORDINATOR
Phone Number:	6126675595
Email Address:	JACOB.WYFFELS@WELLSFARGO.COM