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FORM PF-3: BIOGRAPHICAL QUESTIONAIRE FOR PREMIUM FINANCE COMPANIES (Department of Technology and Information)

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BROWSE DEPARTMENT OF TECHNOLOGY AND INFORMATION (DE) FORMS

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1351 West North Street, Dover, DE 19904-2465 •
www.insurance.delaware.gov
(302) 674-7300 Dover • (302) 739-5280 fax • (302) 577-5280 Wilmington
Office of the
Commissioner
Delaware
Department of Insurance
FORM PF-3
BIOGRAPHICAL QUESTIONAIRE FOR
PREMIUM FINANCE COMPANIES
Please include additional pages as needed to complete response.
1. Company Name
: _________________________________________________
2. Office Held: ______________________________________________________________
3. Individual's Name: _______________________________________________________
Date of Birth: ____________ Place of Birth __________________________
4. Current Residential Address: ___________________________________________
5. Current Business Address: ___________________________________________
6. Residential Address for Past Five Years:
• ______________________________________________________________________
• ______________________________________________________________________
• ______________________________________________________________________
• ______________________________________________________________________
• ______________________________________________________________________
7. Education (Beyond High School):
• ____________________________________________________________________________
• ____________________________________________________________________________
• ____________________________________________________________________________
• ____________________________________________________________________________
1351 West North Street, Dover, DE 19904-2465 •
www.insurance.delaware.gov
(302) 674-7300 Dover • (302) 739-5280 fax • (302) 577-5280 Wilmington
8.
Emplo
yment History. (Beginning with current employer, trace back complete history. Show
dates of employment, name and address of company, position held, and duties.)
• ________________________________________________________________________
•
_____________________________________________________________________
• _________________________________________________________________________
•
_____________________________________________________________________
• _________________________________________________________________________
•
_____________________________________________________________________
9.
List any
other companies which you now serve, or within the past five years have
served, as either an officer or director. (List company, position and dates.)
•
_____________________________________________________________________
• _________________________________________________________________________
•
_____________________________________________________________________
• _________________________________________________________________________
•
_____________________________________________________________________
10.
Have you ever been charged with a criminal violation (other than a traffic offense) at
any time? If "yes," provide complete details.
_____________________________________________________________________
_________________________________________________________________________
_____________________________________________________________________
11.
Have you ever held any other license (except a drivers license)
:
☐
Yes
☐
No
If “yes," provide details as to any such license which was ever suspended, revoked, or
renewal refused:
_________________________________________________________________________
_____________________________________________________________________
12.
Have you ever been charged by any regulatory agency, City, County, State or
Federal, with having violated any laws, rules or regulations" Has any company been
so charged, allegedly as a result of any
action or conduct on you part? ☐ Yes ☐ No
If "yes," as to either, submit full details including disposition of charge:
_____________________________________________________________________
_________________________________________________________________________
_____________________________________________________________________
1351 West North Street, Dover, DE 19904-2465 •
www.insurance.delaware.gov
(302) 674-7300 Dover • (302) 739-5280 fax • (302) 577-5280 Wilmington
X
_________________________________
Signature
State of __________________________)
County ___________________________) SS
On the ______ day of _________________, ______, before me, a Notary Public in and for
The State and County aforesaid, personally appeared ___________________________ to me
known to be the individual described in and who executed the aforegoing and did make oath
in due form of law that the matters and facts contained in the aforegoing resume are true and
correct.
X
Notary Public
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FORM PF-3: BIOGRAPHICAL QUESTIONAIRE FOR PREMIUM FINANCE COMPANIES (Department of Technology and Information)

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Completed 13 August 2020

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