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 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 positions 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

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 (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 ever 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

20

(SEAL)

(Notary Public)

My commission expires

Important Notice: Disclosure of this information is required under Illinois Departmental Rules