Fill - Free fillable BIOGRAPHICAL AFFIDAVIT Uniform Certificate of Authority Application (UCAA) (Arizona) PDF form

Applicant Company Name: _____________________________________________________________________________

NAIC No.: _________________________________________________ FEIN: ___________________________________

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FORM 11

Uniform Certificate of Authority Application (UCAA)

BIOGRAPHICAL AFFIDAVIT

To the ext

ent 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.

Specify Purpose for Completion:

Form A: ________________

_________ UCAA Type: _________________________ Other:________________________

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).

Applicant Company Name: ______________________________________________________________________________

Address: ___________________________________________________ City:_____________________________________

State/Province: ___________________________________ Postal Code: _________________ Phone: __________________

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 any other country?

Yes

No

If yes, w

hat country? ____________________________________________________________________________

3. Affiant’s occupation or profession:

4. Affiant’s business address:

Business te

lephone: ______________________________ Business Email: _____________________________________

5. Education

and training:

Dates Attended Degree

College/University City/State (MM/YY) Obtained

____________________________________________

________________________________________________________

Dates Attended Degree

Graduate Studies College/University City/State (MM/YY) Obtained

Other Training: Name City/State 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: ___________________________________

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6. List of memberships in professional societies and associations:

Name of Contact Name Address of Telephone Number

Society/Association Society/Association of Society/Association

____________________________________________________________________________________________________

7. Present or

proposed position with the Applicant Company: _________________________________________________

___________________________________________________________________________________________________

8. List comple

te 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: ______________ P

ostal Code: __________ Phone: ___________ Offices/Positions Held: ___________________

Type of Business: Supervisor/Contact: ______________________________________

Beginning/

Ending

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

Address:

____________________________ City: ________________________ State/Province: ______________________

Country: ______________ P

ostal Code: __________ Phone: ___________ Offices/Positions Held:____________________

Type of Business: Supervisor/Contact: ______________________________________

Beginning/

Ending

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

Address:

____________________________ City: ________________________State/Province: ______________________

Country: ______________ P

ostal Code: __________ Phone: ___________ Offices/Positions Held:____________________

Type of Business: Supervisor/Contact: ______________________________________

Beginning/

Ending

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

Address:

____________________________ City: ________________________State/Province: ______________________

Country: ______________ P

ostal Code: __________ Phone: ___________ Offices/Positions Held:____________________

Type of Business: Supervisor/Contact: ______________________________________

Applicant Company Name: _____________________________________________________________________________

NAIC No.: _________________________________________________ FEIN: ___________________________________

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FORM 11

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

Yes

No

If any clai

ms were made on the bond, give details:____________________________________________________________

____________________________________________________________________________________________________

b. Have you e

ver been denied an individual or position schedule fidelity bond, or had a bond canceled or revoked?

Yes

No

If yes, gi

ve details:_____________________________________________________________________________________

____________________________________________________________________________________________________

10. List an

y 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.

Organizat

ion/Issuer of License: ________________________ Address: _________________________________________

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

License

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

Date Exp

ired (MM/YY): _______________ Reason for Termination: ___________________________________________

Non-Insuranc

e Regulatory Phone Number (if known): ________________________________________________________

Organization/Issuer of License: ________________________ Address: _________________________________________

City: _________________ S

tate/Province: _______________ Country: _______________ Postal Code: ______________

License

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

Date Exp

ired (MM/YY): _______________ Reason for Termination: ___________________________________________

Non-Insuranc

e 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 refused an occupational, professional, or vocational license or permit by any regulatory authority, or any public

administrative, or governmental licensing agency?

Yes

No

Applicant Company Name: _____________________________________________________________________________

NAIC No.: _________________________________________________ FEIN: ___________________________________

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FORM 11

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?

Yes

No

c. Been place

d on probation or had a fine levied against you or your occupational, professional, or vocational license or

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

Yes

No

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

Yes

No

e. Pled guilty

, or nolo contendere, or been convicted of, any criminal offense(s) other than civil traffic offenses?

Yes

No

f. Had adjudica

tion of guilt withheld, 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

No

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

No

h. Been, within t

he last ten (10) years, a party to any civil action involving dishonesty, breach of trust, or a financial

dispute?

Yes

No

i. Had a finding

made by the Comptroller 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

No

j. Had a lien or fore

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

Yes

No

If the response

to any question above is yes, please provide details including dates, locations, disposition, etc. Attach a copy

of the complaint and filed adjudication or settlement as appropriate.

____________________________________________________________________________________________________

Applicant Company Name: _____________________________________________________________________________

NAIC No.: _________________________________________________ FEIN: ___________________________________

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FORM 11

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 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

No

If yes, pleas

e identify the company 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, prov

ide 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. __________

Applicant Company Name: _____________________________________________________________________________

NAIC No.: _________________________________________________ FEIN: ___________________________________

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FORM 11

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

agency?

Yes

No

b. Had its permit, l

icense, 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 pla

ced 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

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 by means of physical presence or online notarization, 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

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FORM 11

Applicant Company Name: _____________________________________________________________________________

NAIC No.: _________________________________________________ FEIN: ___________________________________

BIOGRAPHICAL AFFIDAVIT

Supplemental Personal Information

To the ex

tent 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.

Specify Purpose for Completion:

Form A: _________________________ UCAA Type: _________________________Other:________________________

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).

Applicant Company Name: _____________________________________________________________________________

Address: ___________________________________________________ City:____________________________________

State/Province: __________________________________ Postal Code: _________________ Phone: __________________

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

No

If yes, give the

reason if any, 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 provide

d 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 Soci

al Security Number: ____________________________________________________________________

4. Government Iden

tification Number if not a U.S. Citizen:

Government ID Number: Country of Issuance:

_________________________________________________ __________________________________________________

5. Foreign Student

ID# (if applicable) : _______________________________________________________________

<Enter App. Co.

Zip/Postal Code>

<Enter App. Co.

Phone>

Applicant Company Name: _____________________________________________________________________________

NAIC No.: _________________________________________________ FEIN: ___________________________________

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FORM 11

6. Date of Birth: (MM/DD/YY) : __________________ Place of Birth, City: ____________________________________

State/Province: ______________________________ Country: _____________________________________________

7. Name of Affian

t’s Spouse (if applicable) : ______________________________________________________________

8. List your resid

ences 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 prov

ided 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 si

gned 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 acknowle

dge 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 by means of physical presence or

online notarization, this

_____ day of _______________, 20_____ by ______________, and: who is personally known to me, or who

produced the following identification: _________________________________.

___________________________________

[SEAL] Notary Publi

c

___________________________________

Printed Notary Name

___________________________________

My Commission Expires

9

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FORM 11

Applicant Company Name: _____________________________________________________________________________

NAIC No.: _________________________________________________ FEIN: ___________________________________

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 by means of physical presence or online notarization, this

_____ day of _______________, 20_____ by ______________, and: who is personally known to me, or who

produced the following identification: _________________________________.

___________________________________

[SEAL] Not

ary Public

___________________________________

Printed Notary Name

___________________________________

My Commission Expires

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FORM 11

Applicant Company Name: _____________________________________________________________________________

NAIC No.: _________________________________________________ FEIN: ___________________________________

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.