Section 2905.EXHIBIT B Utilization Review Organization Officers and Directors Biographical Affidavit

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

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 is insufficient to answer any question fully.) If answer is "No" or "None", so state.

Affiant's full name (initials not acceptable)

2a.

Have you ever had your name changed? Yes No If yes, give the reason for the change.

2b.

Give other names used at any time

Affiant's Social Security No.

4. Date and place of birth

Affiant's business address

Business telephone #

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

Date

Address

City and State

Education: List dates, names, locations and degrees

College:

Graduate Studies:

Others:

List memberships in Professional Societies and Associations

Present or proposed positions with the applicant company

10.

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

Dates

Employer and Address

Title

Please check one

11.

May present employer be contacted? Yes No May former employers be contacted? Yes No

12a.

Have you ever been in a position that required a fidelity bond? Yes No

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? Yes No If yes, give details.

13.

List any professional, occupational, and vocational licenses issued by any public or governmental licensing agency or regulatory authority that 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 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?

Yes No 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 (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? Yes No

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

17.

Have you ever been adjusted bankrupt? Yes No

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? Yes No If yes, give details.

19.

Has any company been charged as described in No. 18, allegedly as a result of any action or conduct on your part? Yes No 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 that, while you occupied such position or capacity, became insolvent or was placed under supervision or in receivership, rehabilitation, liquidation or conservatorship?

Yes No

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? Yes No If yes, give details.

Declaration

Dated and signed this

day of

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 or she executed the above instrument and that the statements and answers contained therein are true and correct to the best of his or her knowledge and belief.

Subscribed and sworn to before me this

day of

(SEAL)

(Notary Public)

My commission expires

Important Notice: Disclosure of this information is required by 50 Ill. Adm. Code 2905