Notification of Changes for Business Entity
General Information
Business Entity Name:	GOLDENCARE USA, INC.
Incorporation / Formation Date:
FEIN:	41-1386011
Ohio License Number:	28680
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
TODD ANDERSON	VP MARKETING	261408	YES		12/01/17
JEFFREY CLARK	AGENT	3700047	YES		12/05/17
TIMOTHY CASEY	AGENT	69797	YES		12/05/17
THOMAS WRIGHT	AGENT	1055626	YES		12/05/17
JULIE ANDERSON-SIMONSON	AGENT	15829354	YES		12/05/17
ARSENIO BAYLON	AGENT	1330041	YES		12/05/17
DENNIS CONWELL	AGENT	3665071	YES		12/05/17
KENNETH DELEO	AGENT	7620726	YES		12/05/17
CASEY EARL	AGENT	18334395	YES		12/05/17
HOWARD GATZKE	AGENT	1573588	YES		12/05/17
GRACE GULDEN	AGENT	6931566	YES		12/05/17
JASON HUNDLEY	AGENT	18111314	YES		12/05/17
DARRELL HUSEBY	AGENT	660122	YES		12/05/17
MICHAEL JOHNSON	AGENT	44535	YES		12/05/17
JODI KIME	AGENT	13217530	YES		12/05/17

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
TODD ANDERSON	VP MARKETING	967446	YES		12/01/17
LORI FJELSTAD	VP ADMINISTRATION	472-86-4690	YES		12/01/17

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