Notification of Changes for Business Entity
General Information
Business Entity Name:	G D VAN WAGENEN FINANCIAL SERVICES INC
Incorporation / Formation Date:
FEIN:	59-3689437
Ohio License Number:	30029
NPN:	6407997
DBA / Trade Name:
State of Domicile:	MN
County:	HENNEPIN
Business Address
Address 1:	6509 FLYING CLOUD DR
Address 2:	STE 100
City:	EDEN PRAIRIE
State:	FL
Zip:	55344
Phone:	800-627-0000
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	11101 ROOSEVELT BLVD N
Address 2:
City:	ST PETERSBURG
State:	FL
Zip:	33716
Indicate the type of change you are seeking
Address Change:	YES
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date

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:	MICHELE CHENEY
Title:	COMPLIANCE MANAGER
Phone Number:	800-627-0000
Email Address:	COMPLIANCE@BANKERSINSURANCE.COM