Illinois Department of Insurance

320 W. Washington Street

Springfield, IL 62767-0001

Full name and address of company (do not use group names)

In connection with the above-named company, I herewith make representations and supply information about myself as hereinafter set forth.  (Attach addendum or separate sheet if space hereon is insufficient to answer any question fully.)  If answer is "No" or "None," so state.

1.

Affiant's full name (initials not acceptable)

2a.

Have you ever had your name changed?

_____

If yes, give the reason for the change.

______________________

2b.

Give other names used at any time

3.

Affiant's Social Security #

4.  Date and place of birth

5.

Affiant's business address

Business Telephone #

6.

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

Date

Address

City and State

7.

Education:  List dates, names, locations and degrees

College:

Graduate Studies:

Others:

8.

List memberships in Professional Societies and Associations

9.

Present or proposed position with the applicant company

10 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

Please circle one:

11.

May present employer be contacted?

Yes

No

May former employers be contacted?

Yes

No

_12a.

Have you ever been in a position which required a fidelity bond?

If any claims were made on the bond, give details.

_12b.

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 administrators, insurers or HMOs in which you control directly or indirectly or own legally or beneficially 10% or more of the outstanding stock standing 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  administrator or its affiliates?     _____   If any of the shares of stock are pledged or hypothecated in any way, give details.  _________________________________

_________________________________________________________________________________________________________________

17.

Have you every been adjudged bankrupt?  ______________

18.

Have you ever been convicted or had a sentence imposed or suspended or had pronouncement of a sentence suspended or been  pardoned  for conviction of or pleaded guilty or nolo contendere to any information or an 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 the subject of any disciplinary proceedings of any federal or state regulatory agency?  _______    If yes, give  details.  ______________________

_________________________________________________________________________________________________________________

19.

Has any company been so charged, allegedly as a result of any action or conduct on your part?  ______    If  yes,  give details  _______________

_________________________________________________________________________________________________________________

20.

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

21.

Has the certificate of authority or license to do business of any insurance company or registration of any administrator of which you were an officer or director or key management person ever been suspended, revoked or denied while you occupied such position? ____If yes, give details. _________________________________________________________________________________________________________________

Declaration

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.

_________________________________

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_______________________________________________________________.

Important Notice:  Disclosure of this information is required under Illinois Departmental Rules.  This form has been approved by the Forms Management Center.