Fill - Free fillable BIOGRAPHICAL AFFIDAVIT To the extent permitted by law, (Arizona) PDF form

Applicant Company Name : _____________________________ NAIC No. __________________________

FEIN: __________________________

Ó2019 National Association of Insurance Commissioners 1

Revised 04/08/19

FORM 11

Uniform Certificate of Authority Application (UCAA)

BIOGRAPHICAL AFFIDAVIT

To the extent permitted by

law, this affidavit will be kept confidential by the state insurance regulatory authority. The affiant

may be required to provide additional information during the third-party verification process if they have attended a foreign

school or lived and worked internationally.

(Print or Type)

Full name, address and telephone number of the present or proposed entity under which this biographical statement is being

required (Do Not Use Group Names).

In connection with the above-named entity, I herewith make representations and supply information about myself

as hereinafter set forth. (Attach addendum or separate sheet if space hereon is insufficient to answer any question

fully.) IF ANSWER IS “NO” OR “NONE,” SO STATE. ALL FIELDS MUST HAVE A RESPONSE. INCOMPLETE

FORMS COULD DELAY THE APPLICATION PROCESS or RESULT IN REJECTION OF THE APPLICATION.

1. Affiant’s Full Name (Initials Not Acceptable): First:___________Middle:____________Last:________________

2. a.

Are you a citizen of the United States?

Yes No

b. Are you a citizen of an

y other country?

Yes

If yes, what country? _______________________________

______

3. Affiant’s occupation or profession:

4. Affiant’s business address:

Business telephone: ________________ Busine

ss Email: _____________________________________

5. Education and training:

College/University City/State Dates Attended (MM/YY) Degree Obtained

___________

Graduate Studies College/Unive

rsity City/State Dates Attended (MM/YY) Degree Obtained

Other Training: Name City/St

ate Dates Attended (MM/YY) Degree/Certification Obtained

Note: If affiant attended a

foreign school, please provide full address and telephone number of the college/university. If

applicable, provide the foreign student Identification Number and/or attach foreign diploma or certificate of

attendance to the Biographical Affidavit Personal Supplemental Information.

Applicant Company Name : _____________________________ NAIC No. __________________________

FEIN: __________________________

Ó2019 National Association of Insurance Commissioners 2

Revised 04/08/19

FORM

6. List of memberships in professional societies and associations:

Name of

Society/Association

Contact Name

Address of

Society/Association

Telephone Number

of Society/Association

7. Present

or proposed position with the Applicant Company: _____________________________________________

_____________________________________________________________________________________________

8. List complete employment record for the past twenty (20) years, whether compensated or otherwise (up to and

including present jobs, positions, partnerships, owner of an entity, administrator, manager, operator, directorates or

officerships). Please list the most recent first. Attach additional pages if the space provided is insufficient. It is only

necessary to provide telephone numbers and supervisory information for the past ten (10) years. Additional

information may be required during the third-party verification process for international employers.

Beginning/Ending

Dates (MM/YY): ________ - _________ Employer’s Name: __________________________________________________

Address: ____________________________ City:________________________ State/Province: ______________________

Country: _____________ Postal Code: __________ Phone: ___________ Offices/Positions Held: ___________________

Type of Business: Supervisor/Contact: _______________________________________

Beginning/

Ending

Dates (MM/YY): ________ - _________ Employer’s Name: __________________________________________________

Address: ____________________________ City: _______________________ State/Province: ______________________

Country: _____________ Postal Code: __________ Phone: ___________ Offices/Positions Held: ____________________

Type of Business: Supervisor/Contact: _______________________________________

Beginning/

Ending

Dates (MM/YY): ________ - _________ Employer’s Name: __________________________________________________

Address: ____________________________ City:________________________ State/Province: ______________________

Country: _____________ Postal Code: __________ Phone: ____________ Offices/Positions Held: ____________________

Type of Business: Supervisor/Contact: _______________________________________

Beginning/

Ending

Dates (MM/YY): ________ - _________ Employer’s Name: __________________________________________________

Address: ____________________________ City:________________________ State/Province: _______________________

Country: _____________ Postal Code: __________ Phone: ____________ Offices/Positions Held: ____________________

Type of Business: Supervisor/Contact: _______________________________________

Applicant Company Name : _____________________________ NAIC No. __________________________

FEIN: __________________________

Ó2019 National Association of Insurance Commissioners 3

Revised 04/08/19

FORM 11

9. a. Have you ever been in a position which required a fidelity bond?

Yes

If any cla

ims were made on the bond, give details: _____________________________________________

_____________________________________________________________________________________

b. Have you ever been denied an individual or position schedule fidelity bond, or had a bond canceled or

revoked?

Yes

If yes,

give details:

10. List

any professional, occupational and vocational licenses (including licenses to sell securities) issued by any public

or governmental licensing agency or regulatory authority or licensing authority that you presently hold or have held

in the past. For any non-insurance regulatory issuer, identify and provide the name, address and telephone number of

the licensing authority or regulatory body having jurisdiction over the license (s) issued. If your professional license

number is your Social Security Number (SSN) or embeds your SSN or any sequence of more than five numbers that

are reasonably identifiable as your SSN, then write SSN for that portion of the professional license number that is

represented by your SSN. (For example, “SSN”, “12-SSN-345” or “1234-SSN” (last 6 digits)). Attach additional

pages if the space provided is insufficient.

_____________________________________________________________________________________________

Organization/Issuer of License: ________________________ Address: __________________________________________

City: ________________ State/Province: _______________ Country: _________________ Postal Code: ______________

License Type: ________________ License #: ___________________ Date Issued (MM/YY): _______________________

Date Expired (MM/YY): _______________ Reason for Termination: ___________________________________________

Non-Insurance Regulatory Phone Number (if known): ________________________________________________________

Organization/Issuer of License: ________________________ Address: __________________________________________

City: ________________ State/Province: _______________ Country: ________________ Postal Code: ______________

License Type: ________________ License #: ___________________ Date Issued (MM/YY): _______________________

Date Expired (MM/YY): _______________ Reason for Termination: ___________________________________________

Non-Insurance Regulatory Phone Number (if known): ________________________________________________________

11. In responding to the following, if the record has been sealed or expunged, and the affiant has personally verified that

the record was sealed or expunged, an affiant may respond “no” to the question. Have you ever:

a. Been re

fused an occupational, professional, or vocational license or permit by any regulatory authority, or

any public administrative, or governmental licensing agency?

Yes

b. Had any occupational, professional, or vocational license or permit you hold or have held, been subject to

any judicial, administrative, regulatory, or disciplinary action?

Applicant Company Name : _____________________________ NAIC No. __________________________

FEIN: __________________________

Ó2019 National Association of Insurance Commissioners 4

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FORM 11

Yes

c. Been placed on probation or ha

d a fine levied against you or your occupational, professional, or vocational

license or permit in any judicial, administrative, regulatory, or disciplinary action?

Yes

d. Been charged with, or indicted for, any criminal offense(s) other than civil traffic offenses?

Yes

e. Pled guilty, or nolo contender

e, or been convicted of, any criminal offense(s) other than civil traffic

offenses?

Yes

f. Had adjudication of guilt withh

eld, had a sentence imposed or suspended, had pronouncement of a sentence

suspended, or been pardoned, fined, or placed on probation, for any criminal offense(s) other than civil

traffic offenses?

Yes

g. Been subject to a cease and desist letter or order, or enjoined, either temporarily or permanently, in any judicial,

administrative, regulatory, or disciplinary action, from violating any federal, state law or law of another country

regulating the business of insurance, securities or banking, or from carrying out any particular practice or

practices in the course of the business of insurance, securities or banking?

Yes

h. Been, within the last te

n (10) years, a party to any civil action involving dishonesty, breach of trust, or a

financial dispute?

Yes

i. Had a finding made by the Co

mptroller of any state or the Federal Government that you have violated any

provisions of small loan laws, banking or trust company laws, or credit union laws, or that you have violated

any rule or regulation lawfully made by the Comptroller of any state or the Federal Government?

Yes

j. Had a lien or foreclosure action

filed against you or any entity while you were associated with that entity?

Yes

If the response to any question a

bove is yes, please provide details including dates, locations, disposition, etc.

Attach a copy of the complaint and filed adjudication or settlement as appropriate.

________________________________________________________________________________________

12. List any entity subject to regulation by an insurance regulatory authority that you control directly or indirectly. The

term “control” (including the terms “controlling,” “controlled by” and “under common control with”) means the

possession, direct or indirect, of the power to direct or cause the direction of the management and policies of a

person, whether through the ownership of voting securities, by contract other than a commercial contract for goods

or non-management services, or otherwise, unless the power is the result of an official position with or corporate

Applicant Company Name : _____________________________ NAIC No. __________________________

FEIN: __________________________

Ó2019 National Association of Insurance Commissioners 5

Revised 04/08/19

FORM 11

office held by the person. Control shall be presumed to exist if any person, directly or indirectly, owns, controls,

holds with the power to vote, or holds proxies representing, ten percent (10%) or more of the voting securities of any

other person.

If any of the stock is pledged or hypothecated in any way, give details.

13. Do [Will] you or members of your immediate family individually or cumulatively subscribe to or own, beneficially

or of record, 10% or more of the outstanding shares of stock of any entity subject to regulation by an insurance

regulatory authority, or its affiliates? An “affiliate” of, or person “affiliated” with, a specific person, is a person that

directly, or indirectly through one or more intermediaries, controls, or is controlled by, or is under common control

with, the person specified.

Yes

If yes, please identify the com

pany or companies in which the cumulative stock holdings represent 10% or more of

the outstanding voting securities.

If any of the shares of stock are pledged or hypothecated in any way, give details.

14. Have you ever been adjudged a bankrupt?

Yes No

If yes, provide details: ________________________

____________________________________________________________________________________________

15. To your knowledge has any company or entity (including entities controlled by the holding company) for

which you were an officer or director, trustee, investment committee member, key management employee or

controlling stockholder, had any of the following events occur while you served in such capacity? If employed at

the holding company level provide the group code. _________________

a. Been refused a permit, license, or certificate of authority by any regulatory authority, or governmental-

licensing agency?

Yes No

b. Had its permit, license, or certificate of authority suspended, revoked, canceled, non-renewed, or

subjected to any judicial, administrative, regulatory, or disciplinary action (including rehabilitation,

liquidation, receivership, conservatorship, federal bankruptcy proceeding, state insolvency, supervision

or any other similar proceeding)?

Yes No

c. Been placed on probation or had a fine levied against it or against its permit, license, or certificate of

authority in any civil, criminal, administrative, regulatory, or disciplinary action?

Yes No

Applicant Company Name : _____________________________ NAIC No. __________________________

FEIN: __________________________

Ó2019 National Association of Insurance Commissioners 6

Revised 04/08/19

FORM

If the answer to any of the above is yes, please indicate and give details. When responding to questions (b) and (c),

affiant should also include any events within twelve (12) months after his or her departure from the entity. ______

___________________________________________________________________________________________

Note: If an affiant has any doubt about the accuracy of an answer, the question should be answered in the positive

and an explanation provided.

Dated and signed this ______ day of __________________ 20 _____ at _________________________ . I hereby certify

under penalty of perjury that I am acting on my own behalf and that the foregoing statements are true and correct to the best

of my knowledge and belief.

___ I hereby acknowledge that I may be contacted to provide additional information regarding international searches.

_____________________________________________

(Signature of Affiant)

State of:_____________________ County of: ____________________

The foregoing instrument was acknowledged before me this ____day of ___________, 20____ by _____________________,

and:

⁭ who is personally known to me, or

⁭ who produced the following identification: _________________________________ .

___________________________________

[SEAL] Notary Public

___________________________________

Printed Notary Name

___________________________________

My Commission Expires

Applicant Company Name : _____________________________ NAIC No. __________________________

FEIN: __________________________

Ó2019 National Association of Insurance Commissioners 7

Revised 04/08/19

FORM 11

BIOGRAPHICAL AFFIDAVIT

Supplemental Personal Information

(Print or Type)

To the extent permitted by law, this affidavit will be kept confidential by the state insurance regulatory authority. The affiant

may be required to provide additional information during the third-party verification process if they have attended a foreign

school or lived and worked internationally.

Full name, address, and telephone number of the present or proposed entity under which this biographical statement is being

required (Do Not Use Group Names).

___________________________________________________________________________________________________

1. Affiant’s Full Name (Initials Not Acceptable): First:_________ Middle:______________ Last:_______________

IF ANSWER IS "NO" OR "NONE," SO STATE. ALL FIELDS MUST HAVE A RESPONSE. INCOMPLETE FORMS

COULD DELAY THE APPLICATION PROCESS or RESULT IN REJECTION OF THE APPLICATION.

2. Have you ever used any other name, including first, middle or last name, nickname, maiden name or aliases?

Yes

If yes, give the reason if a

ny, if none indicate such, and provide the full name(s) and date(s) used.

Beginning/Ending Name(s) Reason (If none, indicate such)

Date(s) Used (MM/YY) Specify: First, Middle or Last Name

________________________ ________________________ __________________________________________

________________________ ________________________

__________________________________________

________________________ ________________________ __________________________________________

Note: Dates provided in response to this question may be approximate. Parties using this form understand that there could

be an overlap of dates when transitioning from one name to another. If applicable, provide the foreign student

Identification Number and/or attach foreign diploma or certificate of attendance to the Biographical Affidavit

Personal Supplemental Information.

3. Affiant’s Social Security Number: _________________________________________________________________

4. Government Identification Number if not a U.S. Citizen: _______________________________________________

5. Foreign Student ID# (if applicable) : _______________________________________________________________

<Tel. Number>

<Tel. Number>

<Tel. Number>

Applicant Company Name : _____________________________ NAIC No. __________________________

FEIN: __________________________

Ó2019 National Association of Insurance Commissioners 8

Revised 04

/08/19

FORM

6. Date of Birth: (MM/DD/YY) : ______________ Place of Birth, City: _____________________________________

State/Province: __________________________ Country: ______________________________________________

7. Name of Affiant’s Spouse (if applicable) : ___________________________________________________________

8. List your residences for the last ten (10) years starting with your current address, giving:

Beginning/Ending State/

Dates (MM/YY) Address City Province Country Postal Code

___________________________________________________________________________________________________

Note: Dates provided in response to this question may be approximate, except for current address. Parties using this form

understand that there could be an overlap of dates when transitioning from one address to another.

Dated and signed this _____ day of ________________, 20_____ at _____________________________________. I hereby

certify under penalty of perjury that I am acting on my own behalf and that the foregoing statements are true and correct to

the best of my knowledge and belief.

___ I hereby acknowledge that I may be contacted to provide additional information regarding international searches.

_________________________________________________

(Signature of Affiant)

State of:_____________________ County of: ___________________

The foregoing instrument was acknowledged before me this _____ day of _______________, 20_____ by ______________,

and:

⁭ who is personally known to me, or

⁭ who produced the following identification: ________________________________

___________________________________

[SEAL] Notary Public

___________________________________

Printed Notary Name

___________________________________

My Commission Expires

Applicant Company Name : _____________________________ NAIC No. __________________________

FEIN: __________________________

Ó2019 National Association of Insurance Commissioners 9

Revised 04

/08/19

FORM

DISCLOSURE AND AUTHORIZATION CONCERNING BACKGROUND REPORTS

(All states except California, Minnesota and Oklahoma)

This Disclosure and Authorization is provided to you in connection with pending or future application(s) of

____________________________________ [company name](“Company”) for licensure or a permit to organize

(“Application”) with a department of insurance in one or more states within the United States. Company desires to procure a

consumer or investigative consumer report (or both)(“Background Reports”) regarding your background for review by a

department of insurance in any state where Company pursues an Application during the term of your functioning as, or

seeking to function as, an officer, member of the board of directors or other management representative (“Affiant”) of

Company or of any business entities affiliated with Company (“Term of Affiliation”) for which a Background Report is

required by a department of insurance reviewing any Application. Background Reports requested pursuant to your

authorization below may contain information bearing on your character, general reputation, personal characteristics, mode of

living and credit standing. The purpose of such Background Reports will be to evaluate the Application and your background

as it pertains thereto. To the extent required by law, the Background Reports procured under this Disclosure and

Authorization will be maintained as confidential.

You may obtain copies of any Background Reports about you from the consumer reporting agency (“CRA”) that produces

them. You may also request more information about the nature and scope of such reports by submitting a written request to

Company. To obtain contact information regarding CRA or to submit a written request for more information, contact

_____________________________________ [company’s designated person, position, or department, address and

phone].

Attached for your information is a “Summary of Your Rights Under the Fair Credit Reporting Act.”

AUTHORIZATION: I

am currently an Affiant of Company as defined above. I have read and understand the above

Disclosure and by my signature below, I consent to the release of Background Reports to a department of insurance in any

state where Company files or intends to file an Application, and to the Company, for purposes of investigating and reviewing

such Application and my status as an Affiant. I authorize all third parties who are asked to provide information concerning

me to cooperate fully by providing the requested information to CRA retained by Company for purposes of the foregoing

Background Reports, except records that have been erased or expunged in accordance with law.

I understand that I may revoke this Authorization at any time by delivering a written revocation to Company and that

Company will, in that event, forward such revocation promptly to any CRA that either prepared or is preparing Background

Reports under this Disclosure and Authorization. This Authorization shall remain in full force and effect until the earlier of

(i) the expiration of the Term of Affiliation, (ii) written revocation as described above, or (iii) six (6) months following the

date of my signature below.

A true copy of this Disclosure and Authorization shall be valid and have the same force and effect as the signed original.

___________________________________________________________________________________________________

(Printed Full Name and Residence Address)

__________________________________________ ____________________________

(Signature) (Date)

State of: _______________ County of: ________________

The foregoing instrument was acknowledged before me this _____ day of ______________, 20_____ by

____________________________________, and:

⁭ who is personally known to me, or

⁭ who produced the following identification: _________________________________

___________________________________

[SEAL] Notary Public

___________________________________

Printed Notary Name

___________________________________

My Commission Expires

Applicant Company Name : _____________________________ NAIC No. __________________________

FEIN: __________________________

Ó2019 National Association of Insurance Commissioners 10

Revised 04/08/19

FORM 11

DISCLOSURE AND AUTHORIZATION CONCERNING BACKGROUND REPORTS

(Minnesota and Oklahoma)

This Disclosure and Authorization is provided to you in connection with pending or future application(s) of

__________________________[company name](“Company”) for licensure or a permit to organize (“Application”) with a

department of insurance in one or more states within the United States. Company desires to procure a consumer or

investigative consumer report (or both)(“Background Reports”) regarding your background for review by a department of

insurance in any state where Company pursues an Application during the term of your functioning as, or seeking to function

as, an officer, member of the board of directors or other management representative (“Affiant”) of Company or of any

business entities affiliated with Company (“Term of Affiliation”) for which a Background Report is required by a department

of insurance reviewing any Application. Background Reports requested pursuant to your authorization below may contain

information bearing on your character, general reputation, personal characteristics, mode of living and credit standing. The

purpose of such Background Reports will be to evaluate the Application and your background as it pertains thereto. To the

extent required by law, the Background Reports procured under this Disclosure and Authorization will be maintained as

confidential.

You may request more information about the nature and scope of Background Reports produced by any consumer reporting

agency (“CRA”) by submitting a written request to Company. You should submit any such written request for more

information, to ______________________ [company’s designated person, position, or department, address and phone].

Attached for your information is a “Summary of Your Rights Under the Fair Credit Reporting Act.” You will be provided

with a copy of any Background Report procured by Company if you check the box below.

⁭ By checking this box, I request a copy of any Background Report from any CRA retained by Company, at no

extra charge.

AUTHORIZATION: I am currently an Affiant of Company as defined above. I have read and understand the above