California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 4 - Insurer Securities Permits › Article 13 - Forms and Addenda › Section 2613.07 - Biographical Affidavit Form

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The following affidavit will be required of the organizers,
					 promoters, original officers and directors of all applicants for organizational
					 permits, and may be required in the case of unseasoned applicants.
Permit____________________
or Admission ____________________
Name of Company applying for Permit or Certificate of
					 Authority:
___________________________
In connection with the application of the above named
					 company to the California Insurance Commissioner for a permit or admission, I
					 herewith make representations and supply information about myself as
					 hereinafter set forth. I make these statements under oath. (Attach addenda on
					 separate sheet if space hereon is insufficient to answer any question fully. If
					 answer is "None" or "No exceptions," so state.
1. Affiant's Full Name:
				  ____________________
2. Aliases
				  used at any time: ____________________
3. Born ____________________ (Date) at
				  ____________________(Place)
4.
				  Color of Hair ____________________, Eyes ____________________,
				  Height____________________
5. Schooling (check those applicable)
High
							 School
___________________________
College
___________________________
Graduate
							 or
___________________________
Professional
___________________________
Degrees
							 (list)
___________________________
___________________________
6. Member of Professional Societies or
				  Associations. List: ___________________________
___________________________
___________________________
___________________________
7. I control directly or indirectly, or own
				  legally or beneficially 10% or more of the outstanding capital stock (in voting
				  power) of, the following insurers: ___________________________
____________________________
___________________________
___________________________
8. Present Chief Occupation.
___________________________
Position or Title:
___________________________
Employer:Name
___________________________
Address
___________________________
How long in this position?
___________________________
How long with this employer?
___________________________
Where?
___________________________
9. Other jobs, positions, directorates, or
				  officership concurrently held at present:
___________________________
___________________________
___________________________
___________________________
10. Others held in the past:
___________________________
___________________________
___________________________
11. If the answers to the foregoing do not
				  show your
complete
experience
in or with the insurance
				  industry,
detail the remainder on the back of this page. List names
				  and addresses of insurance employers and positions held and approximate dates.
___________________________
12. For the last 10 years, I have lived at
				  the following address or addresses:
___________________________
___________________________
___________________________
___________________________
13. I have never been adjudicated a bankrupt,
				  except as follows:
___________________________
___________________________
___________________________
___________________________
14. I have never been convicted or had a
				  sentence imposed suspended or had pronouncement of a sentence suspended or been
				  pardoned for conviction of, or pleaded guilty of or nole contendere to an
				  information or an indictment charging a felony for embezzlement, theft or
				  larceny, mail fraud, or violating any corporate securities statute or any
				  insurance law, except as follows:
___________________________
___________________________
___________________________
___________________________
15. I presently hold or have held in the past
				  the following professional, occupational and vocational licenses issued by
				  public or governmental licensing agencies or authorities (state date license
				  issued, issuer of license, date terminated, reason for termination)
___________________________
___________________________
___________________________
___________________________
16. During the last 10 years I have neither
				  been refused a professional, occupational or vocational license by any public
				  or governmental licensing agency or regulatory authority, nor has such a
				  license held by me ever been suspended or revoked, except as follows:
___________________________
___________________________
___________________________
___________________________
17. I have never been named defendant in a
				  suit brought by any public or governmental licensing agency or regulatory
				  authority for violation of or to prevent the violation of any securities or
				  insurance law, except as follows:
___________________________
___________________________
___________________________
___________________________
18. I have never been made the subject of a
				  cease and desist order by any federal or state securities regulatory agency,
				  except as follows:
___________________________
___________________________
___________________________
___________________________
19. I have never been an officer, director,
				  trustee, investment committee member, key employee or controlling stockholder
				  of an insurer which, while I occupied any such position or capacity with
				  respect to it, became insolvent or was placed in conservatorship, or was
				  enjoined from or ordered to cease and desist from violating any securities or
				  insurance law, except as follows:
___________________________
___________________________
___________________________
___________________________
20. The certificate of authority or license
				  to do business of any insurance company of which I was an officer or director
				  or key management person has never been suspended or revoked while I occupied
				  such position, except as follows:
___________________________
___________________________
___________________________
___________________________
21. No insurer of which I was an officer,
				  director or key management person at the time has ever been denied or refused a
				  license or certificate of authority or withdrawn an application therefor,
				  except as follows:
___________________________
___________________________
___________________________
___________________________
22. (Complete for Permits only) The shares in
				  the original issue (the subject of this organizational permit), subscribed for
				  by me as a member of the group consisting of promoters, organizers, initial
				  officers and directors, will be purchased with funds that are now, or will at
				  the time of purchase be, my property, and no other person will have any legal
				  or equitable interest in said shares, after purchase except as follows:
___________________________
___________________________
___________________________
____________________
(Signature of Affiant)
NOTE:
If this is executed in a state other
					 than California, it is to be sworn to before a Notary Public and his official
					 certificate attached hereto. If executed in California, affiant shall certify
					 to the truth of the statements contained hereon and attached hereto, by
					 completing and subscribing to the following:
STATE OF CALIFORNIA
)
)
ss
___________________________COUNTY OF
)
I hereby certify under penalty of perjury that the
					 foregoing statements are true and correct.
__________
(Signature of Affiant)
Insurance Code Section
					 717,
					 718,
					 843.