Applicant Company Name : _____________________________
NAIC No. _________________________
To the extent permitted by law, this affidavit will be kept confidential by the state insurance regulatory authority.
(Print or Type)
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).
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.
Affiant’s Full Name (Initials Not Acceptable): First:___________Middle:____________Last:________________
Are you a citizen of the United States?
Are you a citizen of any other country?
If yes, what country? _____________________________________