Applicant Company Name: _____________________________________________________________________________
NAIC No.: _________________________________________________ FEIN: ___________________________________
© 2021 National Association of Insurance Commissioners
1
Revised 12/08/2020
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.
<Enter the Applicant Company Name for a Single Company>
<See UCAA FAQs for details>
<See UCAA FAQs for details>
<See UCAA FAQs for details>
<Enter the Applicant Company Name for a Single Company>
<Enter Applicant Company Address>
<Enter Applicant Company State/Province>
<Enter App. Co. Zip/Postal Code>
<Enter App. Co. Phone>
Applicant Company Name: _____________________________________________________________________________
NAIC No.: _________________________________________________ FEIN: ___________________________________
© 2021 National Association of Insurance Commissioners
2
Revised 12/08/2020
FORM 1
1
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):_________-_________ Employers 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):_________-_________ Employers Name: ___________________________________________________
Address:
____________________________ City: ________________________State/Province: ______________________
Country: ______________ P
ostal Code: __________ Phone: ___________ Offices/Positions Held:____________________
Type of Business: Supervisor/Contact: ______________________________________
<Enter the Applicant Company Name for a Single Company>
Applicant Company Name: _____________________________________________________________________________
NAIC No.: _________________________________________________ FEIN: ___________________________________
© 2021 National Association of Insurance Commissioners
3
Revised 12/08/2020
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
<Enter the Applicant Company Name for a Single Company>
Applicant Company Name: _____________________________________________________________________________
NAIC No.: _________________________________________________ FEIN: ___________________________________
© 2021 National Association of Insurance Commissioners
4
Revised 12/08/2020
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.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
<Enter the Applicant Company Name for a Single Company>
Applicant Company Name: _____________________________________________________________________________
NAIC No.: _________________________________________________ FEIN: ___________________________________
© 2021 National Association of Insurance Commissioners
5
Revised 12/08/2020
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. __________
<Enter the Applicant Company Name for a Single Company>
Applicant Company Name: _____________________________________________________________________________
NAIC No.: _________________________________________________ FEIN: ___________________________________
© 2021 National Association of Insurance Commissioners
6
Revised 12/08/2020
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
<Enter the Applicant Company Name for a Single Company>
© 2021 National Association of Insurance Commissioners
7
Revised 12/08/2020
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 the Applicant Company Name for a Single Company>
<See UCAA FAQs for details>
<See UCAA FAQs for details>
<See UCAA FAQs for details>
<Enter the Applicant Company Name for a Single Company>
<Enter Applicant Company Address>
<Enter Applicant Company City>
<Enter Applicant Company State/Province>
<Enter App. Co.
Zip/Postal Code>
<Enter App. Co.
Phone>
Applicant Company Name: _____________________________________________________________________________
NAIC No.: _________________________________________________ FEIN: ___________________________________
© 2021 National Association of Insurance Commissioners
8
Revised 12/08/2020
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
<Enter the Applicant Company Name for a Single Company>
© 2021 National Association of Insurance Commissioners
9
Revised 12/08/2020
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
<Enter the Applicant Company Name for a Single Company>
© 2021 National Association of Insurance Commissioners
10
Revised 12/08/2020
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.
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] Notary Public
___________________________________
Printed Notary Name
___________________________________
My Commission Expires
<Enter the Applicant Company Name for a Single Company>
Applicant Company Name: _____________________________________________________________________________
NAIC No.: _________________________________________________ FEIN: ___________________________________
© 2021 National Association of Insurance Commissioners 11
Revised 12/08/2020
FORM 11
DISCLOSURE AND AUTHORIZATION CONCERNING BACKGROUND REPORTS
(California)
This Disclosure and Authorization is provided to you in connection with a pending application 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 any department of insurance in such states where Company is currently pursuing an Application, because you are either
functioning as, or are 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 will be obtained through
______________________________________________ [name of CRA, address](“CRA”). 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.
Under section 1786.22 of the California Civil Code, you may view the file maintained on you by the CRA listed above. You
may also obtain a copy of this file, upon submitting proper identification and paying the costs of duplication services, by
appearing at the CRA in person or by mail; you may also receive a summary of the file by telephone. The CRA is required to
have personnel available to explain your file to you and the CRA must explain to you any coded information appearing in
your file. If you appear in person, you may be accompanied by one other person of your choosing, provided that person
furnishes proper identification.
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. In no event, however, will this authorization remain in effect beyond 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] No
tary Public
_______________________________________
Printed Notary Name
_______________________________________
My Commission Expires
<Enter the Applicant Company Name for a Single Company>
Applicant Company Name: _____________________________________________________________________________
NAIC No.: _________________________________________________ FEIN: ___________________________________
© 2021 National Association of Insurance Commissioners
12
Revised 12/08/2020
FORM 11
Addendum pages are used for additional responses carried over from the biographical affidavit questions. Responses must be labeled and
signed by the affiant. Attachments included as addendum's must also be signed by the affiant. Refer to the FAQ's on the UCAA webpage
for additional questions.
<Enter the Applicant Company Name for a Single Company>
Applicant Company Name: _____________________________________________________________________________
NAIC No.: _________________________________________________ FEIN: ___________________________________
© 2021 National Association of Insurance Commissioners
13
Revised 12/08/2020
FORM 11
Addendum pages are used for additional responses carried over from the biographical affidavit questions. Responses must be labeled and
signed by the affiant. Attachments included as addendum's must also be signed by the affiant. Refer to the FAQ's on the UCAA webpage
for additional questions.
<Enter the Applicant Company Name for a Single Company>
Applicant Company Name: _____________________________________________________________________________
NAIC No.: _________________________________________________ FEIN: ___________________________________
© 2021 National Association of Insurance Commissioners
14
Revised 12/08/2020
FORM 11
Addendum pages are used for additional responses carried over from the biographical affidavit questions. Responses must be labeled and
signed by the affiant. Attachments included as addendum's must also be signed by the affiant. Refer to the FAQ's on the UCAA webpage
for additional questions.
<Enter the Applicant Company Name for a Single Company>