Department of Insurance, Securities and Banking

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Biographical Affidavit

Friday, September 28, 2012

 A biographical affidavit must be completed by each director, officer, and service provider, including the captive manager, attorney, CPA, actuary, managing general underwriter, managing general agent, organizer, sponsor or promoter, including such persons who will own more than 10 percent of the outstanding shares of the applicant, or who will be providing more than 25 percent of the applicant’s initial capital or surplus.  Answer each question on this application and provide a detailed explanation where necessary.  Do not leave a question blank.  Incomplete applications will be returned.