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: Social Security # Full Name Maiden Name Birth Date Birth Place E-mail address Occupation or Profession 2. Full name and address of the present or proposed entity under which this biographical statement is required: Full Name City Street Address State Zip Business Phone E-mail Address 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 PHONE 6. Education: Dates, Names, Locations and Degrees College / University DATES NAMES CITY / STATE DEGREES CITY / STATE DEGREES Other Institutions DATES NAMES 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 BIOGRAPHICAL STATEMENT AND AFFIDAVIT FORM NON-TRADITIONAL ENTITIES 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 12. (a) Have you been in a position which required a fidelity bond? If any claims were made on the bond, give details. NO YES (b) If "Yes", list all other names used and 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 13. 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 BIOGRAPHICAL STATEMENT AND AFFIDAVIT FORM NON-TRADITIONAL ENTITIES GID-052-NT FEB11 (same as GID-052-EN) 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 License Number(s) 15. Have you ever been licensed to practice medicine or dentistry ? State(s) License Dates If yes, give details. NO Name of Issuer of License(s) YES License Number(s) 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? YES NO If "Yes", what country? 20. 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? YES NO (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? YES NO (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? YES NO (d) Been charged with, or indicted for, any criminal offense(s) other than minor traffic offenses? YES NO (e) Plead guilty, or nolo contendere, or been convicted of, any criminal offense(s) other than minor traffic offenses? YES NO (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 offense(s) other than minor traffic offenses? YES NO (g) Been subject to any federal bankruptcy proceeding, state insolvency, supervision, receivership, rehabilitation, liquidation, or conservatorship proceeding, or any othersimilar proceeding? YES NO (h) 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 or state law 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? YES NO (i) Been within the last ten (10) years a party to or subject of any civil action or legal proceedings? YES NO (j) Been convicted or had a sentence imposed or suspended or been pardoned for conviction of, or pleaded guilty or nolo contendere to an indictment charging any crime involving fraud, dishonesty or moral turpitude? YES NO (k) Have you been the subject of any disciplinary proceedings of any federal or state regulatory agency, including, but not limited to, any taxing authorities? YES NO If you answered "Yes" to any questions noted in question 20, you must provide full details (use additional pages, if necessary): 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 4 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 BIOGRAPHICAL STATEMENT AND AFFIDAVIT FORM NON-TRADITIONAL ENTITIES GID-052-NT FEB11 (same as GID-052-EN) 21. (a) For the purpose of this question, if you hold, or have held, any of the following positions with an entity, indicate below: (1) Incorporator YES NO (2) Administrator YES NO (3) Organizer YES NO (4) Subscriber of a corporation YES NO (5) Subscriber to a reciprocal agreement of indemnity YES NO (6) Subscriber to a limited reciprocal YES NO (7) Director YES NO (8) Officer YES NO (9) Manager or operator YES NO (10) Trustee YES NO (11) Owner, if not a corporation YES NO (12) Sole Proprietor YES NO (13) Joint venturer YES NO (14) Partner, including all general and limited partners of a limited partnership YES NO (15) Stockholder owning or holding five (5) percent or more of the outstanding stock of a stock corporation YES NO (16) Member of a non-stock corporation YES NO (17) Person associated or to be associated with the formation or financing of an underwriting member of an Insurance Exchange in any state or country YES NO (18) Attorney in fact for a reciprocal insurer/company or a limited reciprocal insurer/company, if the attorney in fact is an individual YES NO (19) Any position listed in this subparagraph (a) held in an entity serving as attorney in fact for a reciprocal insurer/company or a limited reciprocal insurer/company, if the entity serving as attorney-in-fact is an individual. YES NO (20) Any position listed in this subparagraph (a) held in an incorporated or unincorporated association. YES NO (21) Any other position where the affiant performs any duties similar to those duties performed by persons in the above mentioned positions. YES NO (1) Been refused a permit, license, or certificate of authority by any regulatory authority or governmental licensing agency? YES NO (2) Had its permit, license, certificate of authority suspended, revoked, canceled, non-renewed, or subjected to any judicial, administrative, regulatory or disciplinary action? YES NO 21. (b) Has any entity while you were associated with that entity or within twelve (12) months after you left: 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 5 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 BIOGRAPHICAL STATEMENT AND AFFIDAVIT FORM NON-TRADITIONAL ENTITIES GID-052-NT FEB11 (same as GID-052-EN) (3) Been placed on probation or had a fine levied, against it or against its permit, license, or certificate of authority in any judicial, administrative, regulatory, or disciplinary action? YES NO (4) Been charged with, or indicted for, any criminal offense? YES NO (5) Plead guilty to, or nolo contendere to, or been convicted of any criminal offense? YES NO (6) Had an 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 offense? YES NO (7) Been insolvent or impaired? YES NO (8) Been subject to any federal bankruptcy proceeding, state insolvency, supervision, receivership rehabilitation, liquidation, or conservatorship proceeding, or any other similar proceeding? YES NO (9) Been enjoined, either temporarily or permanently, in any judicial, administrative, regulatory, disciplinary action from violating any federal or state law regulating the business of insurance, securities, or banking, or from carrying out any particular practice or practices in the course of the business insurance, securities, or banking? YES NO (10) Been within the last ten (10) years a party to or subject of any civil action or legal proceeding? YES NO If you answered "Yes" to any questions noted in question 21, you must provide full details (use additional pages, if necessary): ATTESTATION I, the undersigned affiant, under penalty of perjury, do hereby certify and declare that I have carefully examined this document in its entirety, and do solemnly swear, and affirm that all of my responses, information, exhibits, and documentary evidence submitted in support thereof are true and correct to the best of my knowledge. (Printed Name of Attestator) (Position or Title of Attestatior) State of NOTARY Sworn to and Subscribed before Me this Signature Date (Signature of Attestator) County of day of , ( Seal ) My Commission Expires 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 6 American LegalNet, Inc. www.FormsWorkFlow.com