CERTIFICATE OF DISCLOSURE — ARS § 20-233
Insurer Name – provide exact name
Calendar or Fiscal Year End Date
P
ART A: Has any person (a) who is currently an officer, director, incorporator, or (b) who holds or controls over ten
percent (10%) of the issued and outstanding common shares or ten percent (10%) of any other
proprietary, beneficial or membership in the insurer been:
1. Convicted or felony involving a transaction in securities, insurance consumer fraud or antitrust in any
state or federal jurisdiction within the seven-year period immediately preceding the execution of this
certificate?
YES
NO
(MUST BE ANSWERED)
2. Convicted of a felony, the essential elements of which consisted of fraud, misrepresentation, theft by
false pretenses or restraint of trade or monopoly in any state or federal jurisdiction within the seven-
year period immediately preceding the execution of this certificate?
YES
NO
(MUST BE ANSWERED)
3. Subject to an injunction, judgment, decree or permanent order of any state or federal court enter
ed
w
ithin the seven-year period immediately preceding the execution of this certificate where suc
h
i
njunction, judgment, decree or permanent order involved the violation of:
a. F
raud or registration provisions of the securities laws of that jurisdiction: or
b. T
he consumer fraud laws of that jurisdiction: or
c. T
he antitrust or restraint of trade laws of that jurisdiction; or
d. T
he insurance laws of that jurisdiction?
YES
NO
(MUST BE ANSWERED)
If your answer to any of the Items A1 through A3 is YES, the following information for each person must be attached.
1. Current full name and all prior names or aliases
used.
2. Full birth name.
3. Present home address.
4. Prior addresses (for immediately preceding seven-
year period).
5. Date and location of birth.
6. The nature and description of each conviction or
judicial action, the date and location, the court
and public agency involved and the file or caus
e
num
ber of the case.
PART B: Has any officer, director, trustee, incorporator of the insurer or shareholder possessing or controlling ten
percent (10%) or more of any proprietary, beneficial or membership interest in the insurer served in any
such capacity or held such interest in any business entity which has been placed in bankruptcy or
receivership or had its charter revoked or Certificate of Authority suspended, refused renewal or revoked