TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051 PREFERRED PROVIDER PROGRAMS
SECTION 2051.APPENDIX E ILLINOIS OR NAIC BIOGRAPHICAL AFFIDAVIT



Section 2051.APPENDIX E   Illinois or NAIC Biographical Affidavit

 

Full name and address of company (do not use group name)

 

 

 

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 question fully.) If answer is "No" or "None", so state.

1.

Affiant's full name (initials not acceptable)

2a.

Have you ever had your name changed? ____ If yes, give the reason for the change

 

 

 

 

 

 

2b.

Give other names used at any time

3.

Affiant's Social Security

4.  Date and place of birth

5.

Affiant's business address

Business Telephone #

6.        List your residences for the last 10 years starting with your current address, giving:

Date

Address

City and State

 

 

 

 

 

 

 

 

 

 

7.

Education: List dates, names, locations and degrees

 

College:

 

 

 

Graduate Studies:

 

 

 

Others:

 

 

 

 

8.

List memberships in Professional Societies and Associations

9.

Present or proposed positions with the applicant company

10.

List complete employment record (up to and including present jobs, positions, directorates or officerships) for the past 20 years, giving:

Dates

Employer and Address

Title

 

 

 

 

 

 

Please circle one

11.

May present employer be contacted?     Yes      No      May former employers be contacted?      Yes      No

12a.

Have you ever been in a position which required a fidelity bond? ______ If any claims were made on the bond, give details.

 

 

 

 

 

12b.

Have you ever been denied an individual or position schedule fidelity bond, or had a

bond cancelled 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, reasons for termination.)

14.

During the last 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 administrators, insurers or HMOs in which you control directly or indirectly or own legally or beneficially 10% or more of the outstanding stock (in voting power).

 

 

 

If any of the stock is pledged or hypothecated in any way, give details.

 

 

 

 

 

16.

Will you or members of your immediate family subscribe to or own, beneficially or of record, shares of stock of the applicant administrator or its affiliates? _____ If any of the shares of stock are pledged or hypothecated in any way, give details.

 

 

 

 

17.

Have you ever been adjudged bankrupt?

 

 

 

18.

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 contendere to any information or an indictment charging any felony or charging a misdemeanor involving embezzlement, theft, larceny, or mail fraud, or charging a violation of any corporate securities statute or any insurance law, or have you been the subject of any disciplinary proceedings of any federal or state regulatory agency? _______

 

If yes, give details

 

 

 

 

 

 

19.

Has any company been so charged, allegedly as a result of any action or conduct on your

part?

 

If yes, give details.

 

 

 

 

20.

Have you ever been an officer, director, trustee, investment committee member, key employee, or controlling stockholder of any insurer, HMO or administrator 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?

 

 

 

 

 

21.

Has the certificate of authority or license to do business of any insurance company or registration of any administrator of which you were an officer or director or key management person ever been suspended, revoked or denied while you occupied such position? ______

If yes, give details.

 

 

 

 

 

 

 

 

Declaration

Dated and signed this

 

day of

 

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.

 

 

 

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 his knowledge and belief.

Subscribed and sworn to before me this

 

day of

 

20

 

 

 

 

 

(SEAL)

 

(Notary Public)

My commission expires

 

 

Important Notice:  Disclosure of this information is required under Illinois Department of Insurance Rules.

 

 

NAIC BIOGRAPHICAL AFFIDAVIT

 

Applicant Name:

 

 

NAIC No:

 

 

FEIN:

 

 

 

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.

 

1.

a.

Affiant's Full Name (Initials Not Acceptable).

 

 

 

b.

Maiden Name (if applicable).

 

 

 

2.

 

a.

 

Have you ever had your name changed?  If yes, give the reason for the change and provide the full names.

 

 

 

 

 

 

 

 

 

 

 

 

 

b.

Other names used at any time (including aliases).

 

 

 

 

 

 

 

 

 

3.

a.

Are you a citizen of the United States?

 

 

 

b.

Are you a citizen of any other country, if so, what country?

 

 

4.

 

Affiant's Occupation or Profession.

 

 

5.

 

Affiant's business address.

 

 

 

 

Business telephone.

 

 

6.

 

Education and Training:

 

College/ University

City/ State

Dates Attended (MM/YY)

Degree Obtained

 

 

 

Graduate Studies:

College/ University

City/ State

Dates Attended (MM/YY)

Degree 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 in the space provided in the Biographical Affidavit Supplemental Information.)

7.

 

List of memberships in professional societies and associations.

 

Name of

Society/Association

 

Contact Name

Address of

Society/Association

Telephone Number

of Society/Association

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

 

Present or proposed position with the applicant entity.

 

 

9.

 

List complete employment record for the past 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 10 years.

 

 

Beginning/Ending

Dates (MM/YY)

 

-

 

Employer's Name

 

Address

 

City

 

State/Province

 

Country

 

Postal Code

 

Phone

 

Offices/Positions Held

 

Supervisor/Contact

 

 

Beginning/Ending

Dates (MM/YY)

 

-

 

Employer's Name

 

Address

 

City

 

State/Province

 

Country

 

Postal Code

 

Phone

 

Offices/Positions Held

 

Supervisor/Contact

 

 

Beginning/Ending

Dates (MM/YY)

 

-

 

Employer's Name

 

Address

 

City

 

State/Province

 

Country

 

Postal Code

 

Phone

 

Offices/Positions Held

 

Supervisor/Contact

 

 

Beginning/Ending

Dates (MM/YY)

 

-

 

Employer's Name

 

Address

 

City

 

State/Province

 

Country

 

Postal Code

 

Phone

 

Offices/Positions Held

 

Supervisor/Contact

 

 

10.

a.

Have you ever been in a position which required a fidelity bond?   __________

 

 

If any claims were made on the bond, give details.

 

 

 

 

 

b.

Have you ever been denied an individual or position schedule fidelity bond, or had a bond canceled or revoked? __________ If yes, give details.

 

 

 

11.

 

List any 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 licenses issued. Attach additional pages if the space provided is insufficient.

 

Organization/Issuer of License

 

Address

 

City

 

State/Province

 

Country

 

Postal Code

 

 

License Type

 

License #

 

Date Issued (MM/YY)

 

Date Expired (MM/YY)

 

Reason for Termination

 

Non-insurance Regulatory Phone Number (if known)

 

 

Organization/Issuer of License

 

Address

 

City

 

State/Province

 

Country

 

Postal Code

 

 

License Type

 

License #

 

Date Issued (MM/YY)

 

Date Expired (MM/YY)

 

Reason for Termination

 

Non-insurance Regulatory Phone Number (if known)

 

 

12.           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?

 

 

 

 

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?

 

 

 

 

c.

Been placed 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?

 

 

 

 

d.

Been charged with, or indicted for, any criminal offenses other than civil traffic

 

offenses?

 

 

 

 

e.

Pled guilty, or nolo contendere, or been convicted of, any criminal offenses other

 

than civil traffic offenses?

 

 

 

 

f.

Had adjudication 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 offenses other than civil traffic offenses?

 

 

 

 

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?

 

 

 

 

h.

Been, within the last 10 years, a party to any civil action involving dishonesty,

 

breach of trust, or a financial dispute?

 

 

 

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?

 

 

 

j.

Had a lien; or foreclosure action filed against you or any entity while you were

 

associated with that entity?

 

 

If the response to any question above is answered "Yes", please provide details including dates, locations, disposition, etc. Attach a copy of the complaint and filed adjudication or settlement as appropriate.

 

 

 

 

13.       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, 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.

 

 

 

 

14.       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. If the answer is "Yes", please 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.

 

 

 

 

15.

 

Have you ever been adjudged a bankrupt? ____ If yes, provide details

 

 

 

 

16.       To your knowledge has any company or entity 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 yes, please indicate and give details. When responding to questions (b) and (c) affiant should also include any events within 12 months after his or her departure from the entity.

 

a.          Been refused a permit, license, or certificate of authority by any regulatory authority, or Governmental-licensing agency?

 

b.         Had its permit, license, 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)?

 

c.         Been placed 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?

 

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.

 

 

(Signature of Affiant)

 

Date

State of

 

County of

 

 

 

The foregoing instrument was acknowledged before me this

 

day of

 

,

20

 

By

 

,

 

  who is personally known to me, or

 

  who produced the following identification:

 

 

 

 

[SEAL]

 

Notary Public

 

 

Printed Notary Name

 

 

My Commission Expires

 

(Source:  Appendix E renumbered from Appendix D and amended at 37 Ill. Reg. 2895, effective March 4, 2013)