OFFICE OF COMMISSIONER OF INSURANCE COMMISSIONER OF INSURANCE ·INDUSTRIAL LOAN COMMISSIONER·SAFETY FIRE COMMISSIONER·COMPTROLLER GENERAL Ralph T. Hudgens, Commissioner www.oci.ga.gov 2 Martin Luther King Jr., Dr., Suite 604, West Tower, Atlanta, GA 30334 Phone: 404-656-7556 Fax: 770-344-5798 E-mail: TBrewster@oci.ga.gov NON-TRADITIONAL ENTITIES BIOGRAPHICAL STATEMENT AND AFFIDAVIT FORM GID-052-NT FEB11 (same as GID-052-EN) Fully answer all questions. If a question is not applicable write "N/A". If the space on this form is inadequate, attach additional sheets. List chronological data in reverse order, beginning with the most recent data. Print or type all answers. 1. Person for which this biographical statement is required: Full Name Maiden Name Birth Date E-mail address Birth Place Occupation or Profession Social Security # 2. Full name and address of the present or proposed entity under which this biographical statement is required: Full Name Street Address State 3. Type of entity: 4. Your current or proposed position with the present or proposed entity: 5. List your residence for the last ten (10) years starting with your current address, giving: DATE STREET ADDRESSS CITY / STATE / ZIP Zip Business Phone City E-mail Address PHONE 6. Education: Dates, Names, Locations and Degrees College / University DATES NAMES CITY / STATE DEGREES Other Institutions DATES NAMES CITY / STATE DEGREES This office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs or services. Disabled persons needing this document in another format can contact the ADA Coordinator for this office at No. 2 Martin Luther King Jr., Dr., Suite 620, Atlanta, GA 30334 - Phone 404-656-2056. Page 1 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE OF COMMISSIONER OF INSURANCE COMMISSIONER OF INSURANCE ·INDUSTRIAL LOAN COMMISSIONER·SAFETY FIRE COMMISSIONER·COMPTROLLER GENERAL Ralph T. Hudgens, Commissioner www.oci.ga.gov 2 Martin Luther King Jr., Dr., Suite 604, West Tower, Atlanta, GA 30334 Phone: 404-656-7556 Fax: 770-344-5798 E-mail: TBrewster@oci.ga.gov NON-TRADITIONAL ENTITIES BIOGRAPHICAL STATEMENT AND AFFIDAVIT FORM GID-052-NT FEB11 (same as GID-052-EN) 7. List complete employment record (up to and including present jobs, positions, directorates or officer ships) for the past YES NO ten (10) years, giving: May present employer be contacted? DATES EMPLOYER STREET/CITY/STATE TITLE 8. List other current business activities: 9. (a) Have you or your spouse ever been affiliated or associated with, or in any way connected with, an insurance entity regulated by the GA Office of Commissioner of Insurance? (b) If "Yes" list all such entities: YES NO 10. (a) Do you or members of your immediate family have, or will have an ownership interest of any kind in the present or proposed YES NO entity? (b) If "Yes", list all such ownership interests and give full details. If the ownership interest is pledged or hypothecated in any way, give full details: 11. (a) Have you ever used an alias or a different name? give full explanation and supporting documentation: YES NO (b) If "Yes", list all other names used and 12. (a) Have you been in a position which required a fidelity bond? If any claims were made on the bond, give details. YES NO (b) Have you ever been denied an individual or position schedule fidelity bond, or had a bond cancelled or revoked? YES NO If yes, give details. This office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs or services. Disabled persons needing this document in another format can contact the ADA Coordinator for this office at No. 2 Martin Luther King Jr., Dr., Suite 620, Atlanta, GA 30334 - Phone 404-656-2056. Page 2 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE OF COMMISSIONER OF INSURANCE COMMISSIONER OF INSURANCE ·INDUSTRIAL LOAN COMMISSIONER·SAFETY FIRE COMMISSIONER·COMPTROLLER GENERAL Ralph T. Hudgens, Commissioner www.oci.ga.gov 2 Martin Luther King Jr., Dr., Suite 604, West Tower, Atlanta, GA 30334 Phone: 404-656-7556 Fax: 770-344-5798 E-mail: TBrewster@oci.ga.gov NON-TRADITIONAL ENTITIES BIOGRAPHICAL STATEMENT AND AFFIDAVIT FORM GID-052-NT FEB11 (same as GID-052-EN) 13. Have you ever been licensed as an insurance agent, broker, solicitor, adjuster, or counselor in Georgia or any other state? If yes, give details. YES NO State/Federal License Dates License Numbers Name of Issuer of License(s) 14. Have you ever been licensed to sell securities? State/Federal License Dates YES NO If yes, give details. Name of Issuer of License(s) License Number(s) 15. Have you ever been licensed to practice medicine or dentistry ? State(s) License Dates License Number(s) YES NO If yes, give details. Name of Issuer of License(s) 16. 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 Licensed License Number(s) Date Terminated Reason For Termination 17. (a) List any entities regulated by the GA Office of Commissioner of Insurance in which you control directly or indirectly or own legally or beneficially five (5) percent or more of the outstanding stock (in voting power): (b) Is any of the stock pledged or hypothecated in any way? pledged or hypothecated in any way, give details YES NO If any of the stock is This office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs or services. Disabled persons needing this document in another format can contact the ADA Coordinator for this office at No. 2 Martin Luther King Jr., Dr., Suite 620, Atlanta, GA 30334 - Phone 404-656-2056. Page 3 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE OF COMMISSIONER OF INSURANCE COMMISSIONER OF INSURANCE ·INDUSTRIAL LOAN COMMISSIONER·SAFETY FIRE COMMISSIONER·COMPTROLLER GENERAL Ralph T. Hudgens, Commissioner www.oci.ga.gov 2 Martin Luther King Jr., Dr., Suite 604, West Tower, Atlanta, GA 30334 Phone: 404-656-7556 Fax: 770-344-5798 E-mail: TBrewster@oci.ga.gov NON-TRADITIONAL ENTITIES BIOGRAPHICAL STATEMENT AND AFFIDAVIT FORM GID-052-NT FEB11 (same as GID-052-EN) 18. List memberships in professional societies and associations: 19. Are you a citizen of any country other than the United States? 20. Have you ever: YES NO If "Yes", what country? (a) Been refused an occupational, professional, or vocati