Fillable State of New Hampshire (State of New Hampshire)

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State of New Hampshire (State of New Hampshire)

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The State of New Hampshire (State of New Hampshire) form is 4 pages long and contains:

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U.S.A. forms for State of New Hampshire

BROWSE STATE OF NEW HAMPSHIRE (NH) FORMS

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WC- TPA- BA (3/2019) Page 1
State of New Hampshire
Department of Labor
BIOGRAPHICAL AFFIDAVIT
Full Name and Address of Company (Do Not Use Group Names)
In connection with the above-named company, 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 questions fully.) IF ANSWER IS “NO” OR “NONE”, SO STATE.
1. Affiant’s Full Name (Initials Not Acceptable):
___________________________________________________________________________
2. A. Have you ever had your name changed? ____________________ If yes, give the reason for the
change
____________________________________________________________________________
B. Other names used at any time.
____________________________________________________________________________
3. Affiant’s Social Security Number. ______________________________________________
4. Date and Place of Birth.
____________________________________________________________________________
5. Affiant’sBusiness Address. ___________________________________________________
Business Telephone. _________________________________________________
6. List your residences for the last ten (10) years starting with your current address, giving:
Date Address City and State
___________________________________________________________________________
___________________________________________________________________________
Hugh J. Gallen
State Office Park
Spaulding Building
95 Pleasant Street
Concord, NH 03301
603/271-3176
TDD Access: Relay NH
1-800-735-2964
FAX: 603/271-6149
http://www.nh.gov/labor
Ken Merrifield
Commissioner
Rudolph W. Ogden, III
Deputy Commissioner
WC- TPA- BA (3/2019) Page 2
7. Education: Dates, Names, Locations and Degrees.
College:
_________________________________________________________________________
Graduate Studies:
_________________________________________________________________________
Other:
_________________________________________________________________________
_________________________________________________________________________
8. List memberships in Professional Societies and Associations.
_____________________________________________________________________________
_____________________________________________________________________________
9. Present or Proposed Position with the Applicant Company.
_____________________________________________________________________________
10. List complete employment record (up to and including present jobs, positions, directorates or
officerships) for the past twenty (20) years, giving:
DATES EMPLOYER AND ADDRESS TITLE
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
11. Present employer may be contacted. YES NO (Check One)
Former employer may be contacted. YES NO (Check One)
12. A. Have you ever been in a position, which required a fidelity bond? ___________________
If any claims were made on the bond, give details. _______________________________
WC- TPA- BA (3/2019) Page 3
B. Have you ever been denied an individual or position schedule fidelity bond, or have a bond canceled or
revoked?
If yes, give details.
__________________________________________________________________________
__________________________________________________________________________
13. List any professional, occupational and vocational licenses issued by any public or governmental
licensing agency or regulatory authority, which you presently hold or have held in the past (state date license
issued, issuer of license, date terminated, reason for termination).
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
14. During the last ten (10) years, have you ever been refused a professional, occupational or vocational
license by any public or governmental licensing agency or regulatory authority, or has any such license held
by you ever been suspended or revoked? ___________________________
If yes, give details:
___________________________________________________________________________
___________________________________________________________________________
15. List any insurers in which you control directly or indirectly or own legally or beneficially 10% or more of
the outstanding stock (in voting power).
_____________________________________________________________________________
16. Will you or members of your immediate family subscribe to or own, beneficially or of record, shares of
stock of the applicant insurance company or its affiliates?
_____________________________________________________________________________
17. Have you ever been adjudged a bankrupt? ________________________________________
WC- TPA- BA (3/2019) Page 4
18. A. Have you ever been convicted or had a sentence imposed or suspended or had pronouncement of a
sentence suspended or been pardoned for conviction of or pleaded guilty or nolo contend ere to an
information or indictment charging any felony, or charging a misdemeanor involving embezzlement, theft,
larceny, or mail fraud, or charging violation of any corporate securities statute or any insurance law, or have
you been subject of any disciplinary proceedings of any federal or state regulatory agency?
If yes, give details.
____________________________________________________________________________
B. Has any company been so charged, allegedly as a result of any action or conduct on your part?
If yes, give details.
____________________________________________________________________________
19. Have you ever been an office, director, trustee, investment committee member, key employee, or
controlling stockholder of any insurer which, while you occupied any such position or capacity with respect
to it, became insolvent or was placed under supervision or in receivership, rehabilitation, liquidation or
conservatorship? ____________________________
20. Has the certificate of authority or license to do business of any insurance company of which you were an
officer or director or key management person ever been suspended or revoked while you occupied such
position? _____________________________________________________
If yes, give details.
____________________________________________________________________________
____________________________________________________________________________
WC- TPA- BA (3/2019) Page 5
Dated and signed this _______day of ______________at______________________________
______________________________________. I hereby certify under penalty of perjury that I am acting on
behalf, and that foregoing statements are true and correct to the best of my knowledge and behalf.
__________________________________
(Signature of Affiant)
State of__________________________
County of ________________________
Personally appeared before me the above named ____________________________________
personally known to me, who, being duly sworn, deposes and says that he executed the above instrument and
that the statements and answers contained therein are true and correct to the best of my knowledge and belief.
Subscribed and sworn to before me this ______________day of_________________20______
______________________________________
(Notary Public/Justice of the Peace)
My Commission Expires__________________
SEAL
TPA Biographical Affidavit
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State of New Hampshire (State of New Hampshire)

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Completed 21 July 2020

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