1.

Affiant's Full Name (Initials Not Acceptable).

2.

a.

Have you ever had your name changed?

If yes, give the reason for the change.

b.

Other names used at any time.

3.

Affiant's Social Security Number.

4.

Date and Place of Birth.

5.

Affiant's Business Address.

Business Telephone.

6.

List your residence for the last ten (10) years starting with your current address, giving:

DATE

ADDRESS

CITY AND STATE

7.

Education:   Dates, Names, Locations and Degrees.

College

Graduate Studies

Others

8.

List memberships in Professional Societies and Associations.

9.

Present of Proposed Position with the Applicant Company.

10.

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

DATES

EMPLOYER AND ADDRESS

TITLE

11.

Present employer may be contacted.

Yes

No

(Circle One)

Former employers may be contacted.

Yes

No

(Circle One)

12.

a.

Have you ever been in a position which requires 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 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 ten (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 insurers 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 insurance company or its affiliates?

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

17.

Have you ever been adjudged a bankrupt?

18.

a.

Have you ever been convicted or had a sentence imposed or suspended or had pronouncement of a sentence suspended or been pardoned or convicted of or plead guilty or nolo contendere to any information or 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 subject of any disciplinary proceedings of any federal or state regulatory agency?

If yes, give details.

b.

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

If yes, give details.

19.

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

20.

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

If yes, give details.

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.

Signature of Affiant

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

, 19

.

(Notary Public)

(SEAL)

My Commission Expires