Free SI-27 - Florida

STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS COMPENSATION SELF-INSURANCE SECTION BIOGRAPHICAL STATEMENT AND AFFIDAVIT

DEFINITIONS AND INSTRUCTIONS All questions on this form should be answered fully. If a question is not applicable please put "Not Applicable" or "N/A". If more space is needed, please attach additional sheets. Please print or type all answers.

QUESTIONS
1. (a) Full Name_______________________________________(b) Maiden Name_______________________________________ (c) Date of Birth________________________(d) Place of Birth____________________________________________________ (e) Occupation or Profession_________________________________ 2. Full name and address of the present or proposed entity under which this biographical statement is being required. _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ . 3. Name of proposed entity: _________________________________________________________________________________________________________ 4. Your current or proposed position with the present or proposed entity. _________________________________________________________________________________________________________ 5. List your residence for the last ten (10) years starting with your current address and going backward, giving: Dates Address City, County, State Telephone _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ 6. Education. Please list the most recent education first. College/University Dates Attended Degree Obtained _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Other Training _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

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7. Business and employment record for past ten (10) years. Please list the most recent first. Include all director and officer positions held. Dates Employer's Name Address & Telephone Offices/Positions Held _________________________________________________________________________________________________________ _______________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ May present employer be contacted? Yes No 8. List Other current business activities:_________________________________________________________________________ _________________________________________________________________________________________________________ 9. (a) Have you or your spouse ever been affiliated or associated with or in any way connected with an entity regulated by the Department of Financial Services? Yes No (b) If "yes", please list all such entities________________________________________________________________________ _________________________________________________________________________________________________________ 10. (a) Do you or members of your immediate family have or will have an ownership interest of any kind in the present or entity? Yes No proposed

(b) If "yes", list all such ownership interests and give full details. If the ownership interest is pledged or hypothecated in any way, give full details. _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ 11. (a) Have you ever used an alias or a different name? Yes No

(b) If "yes", list all other names used and give full explanation and supporting documentation. _________________________________________________________________________________________________________ 12. (a) Have you ever been bonded? (b) If "yes": 1. Were any claims ever made or attempted to be made against your bond? 2. Has your bond ever been canceled or revoked? 3. Has your application for bond been declined? Yes No

Yes Yes Yes

No No No

4. If the response to 1, 2, or 3 is "yes", please provide reasons__________________________________________________ _________________________________________________________________________________________________________ 13. (a) Have you ever been licensed as an insurance agent, broker, solicitor, adjuster, or claims investigator in Florida or any other state? (b) If "yes": 1. State(s)___________________________________________________________________________________________ 2. Date license(s) held_________________________________________________________________________________ 3. License number(s)__________________________________________________________________________________ 4. Name of issuer of license(s)___________________________________________________________________________ 14. (a) Have you ever been licensed to sell securities? (b) If "yes": 1. By whom (state(s) and/or federal)______________________________________________________________________ 2. Dates license(s) held________________________________________________________________________________ 3. License number(s)__________________________________________________________________________________ 4. Name of issuer of license(s)__________________________________________________________________________ Yes No Yes No

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15. (a) Have you ever been licensed to practice medicine or dentistry? (b) If "yes":

Yes

No

1. State(s)___________________________________________________________________________________________ 2. Dates license(s) held________________________________________________________________________________ 3. License number(s)__________________________________________________________________________________ 4. Name of issuer of license(s)___________________________________________________________________________ 16. List any other occupational, professional, or vocational licenses you have ever held and identify the state(s), the dates license(s) held, and the license number(s): _________________________________________________________________________________________________________ 17. List any entities regulated by the Department in which you control directly or indirectly or own legally or beneficially five (5) percent or more of the outstanding stock (in voting power). _________________________________________________________________________________________________________ If any of the stock is pledged or hypothecated in any way, give details.________________________________________________ _________________________________________________________________________________________________________ 18. List memberships in professional societies and associations._____________________________________________________ 19. Are you a citizen of any country other than the United States? Yes No If "yes", what country?____________________________________________________________________________________ 20. Have you ever: (a) Been refused an occupational, professional, or vocational license or permit Yes No by any regulatory authority, or any public, administrative, or governmental licensing agency? (b) Had any occupational, professional or vocational license or permit you hold, Yes No or have held, been subject to any judicial, administrative, regulatory or disciplinary action? (c) Been placed on probation or had a fine levied against you or your Yes No occupational, professional, or vocational license or permit in any judicial, administrative, regulatory, or disciplinary action? (d) Been charged with, or indicted for, any criminal offense(s) other than minor Yes No traffic offenses? (e) Pled guilty, or nolo contendere, or been convicted of any criminal offense(s) Yes No other than minor traffic offenses? (f) Had adjudication of guilt withheld, had a sentence imposed or suspended, Yes No had pronouncement of a sentence suspended, or been pardoned, fined or placed on probation, for any criminal offense(s) other than minor traffic offenses? (g) Been subject to any federal bankruptcy proceedings, state insolvency, Yes No supervision, receivership, rehabilitation, liquidation, or conservatorship proceeding, or any other similar proceeding? (h) Been subject to a cease and desist letter or order, or enjoined, either Yes No temporarily or permanently, in any judicial, administrative, regulatory, or disciplinary action, from violating any federal or state law regulating the business of insurance, securities or banking, or from carrying out any particular practice or practices in the course of the business of insurance, securities or banking? (i) Been, within the last ten (10) years, a party to any civil action other than for Yes No minor traffic offenses? (j) Had a finding made by any state or the Federal Government that you have Yes No violated any rule or regulation lawfully made by any state or the Federal Government? If the response to any question above is answered "yes", please provide full details. _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

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21.

(a) For the purpose of this question, if you hold or have held any of the following positions with an entity, please indicate below. 1. Incorporator Yes No 2. Administrator 3. Organizer 4. Subscriber of a corporation 5. Subscriber to a reciprocal agreement of indemnity 6. Subscriber of a limited reciprocal 7. Director 8. Officer 9. Manager or operator 10. Trustee 11. Owner, if not a corporation 12. Sole proprietor 13. Joint venturer 14. Partner, including all general and limited partners of a limited partnership. 15. Stockholder owning or holding five (5) percent or more of the outstanding stock of a stock corporation 16. Member of a non-stock corporation 17. Person associated or to be associated with the formation or financing of an underwriting member on an Insurance Exchange in any state or country 18. Attorney in fact for a reciprocal insurer/company or a limited reciprocal insurer/company, if the attorney in fact is an individual 19. Any position listed in this subparagraph (a) held in an entity serving as attorney in fact for a reciprocal insurer/company or a limited reciprocal insurer/ company, if the entity serving as attorney in fact is not an individual 20. Any position listed in this subparagraph (a) held in an incorporated or unincorporated association 21. Any other position where the person filling the position performs any duties similar to those duties performed by persons in the above mentioned positions Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes No No No No No No No No No No No No

Yes Yes

No No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

(b) Has any entity while you were associated with that entity or within twelve (12) months after you left: 1. Been refused a permit, license, or certificate of authority by any regulatory authority, or governmental licensing agency?

Yes

No No

2. Had its permit, license, or certificate of authority suspended, revoked, Yes cancelled, non-renewed, or subjected to any judicial, administrative, regulatory, or disciplinary action? 3. Been placed on probation or had a fine levied against it or against its Yes license, or certificate of authority in any judicial, administrative, regulatory, or disciplinary action? 4. Been charged with, or indicted for any criminal offense? 5. Pled guilty to, or nolo contendere to, or been convicted of any criminal offense? No

Yes Yes

No No

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6. Had an adjudication of guilt withheld, had a sentence imposed or suspended, had pronouncement of a sentence suspended, or been pardoned, fined, or placed on probation for any criminal offense? 7. Been insolvent or impaired? 8. Been subject to any federal bankruptcy proceeding, state insolvency, supervision, receivership, rehabilitation, liquidation, or conservatorship proceeding, or any other similar proceeding? 9. Been enjoined, either temporarily or permanently, in any judicial, administrative, regulatory, or disciplinary action from violating any federal or state law regulating the business of insurance, securities, or banking, or from carrying out any particular practice or practices in the course of business insurance, securities, or banking? 10. Been within the last ten (10) years a party to any civil action?

Yes

No

Yes Yes

No No

Yes

No

Yes

No

(c) If the response to any question above is answered "yes", please provide full details below: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ I HEREBY CERTIFY, under penalty of perjury, that the foregoing answers, statements, and information are true and correct. I, the undersigned affiant, under penalty of perjury, do declare that I have carefully examined each of the questions asked in this BIOGRAPHICAL STATEMENT AND AFFIDAVIT and each of my responses thereto, and do solemnly swear or affirm that all of my responses, information, exhibits, and documentary evidence submitted in support thereof are true and correct. ________________________________________ (Typed Name) ________________________________________ (Signature) ________________________________________ (Date)

State of__________________________________ County of_________________________________ BEFORE ME this day personally appeared____________________________________________(Typed name of Affiant) who, being duly sworn, deposes and says that he-she executed the above BIOGRAPHICAL STATEMENT AND AFFIDAVIT and that the answers, statements, and information contained in this statement are true and correct. Sworn to and subscribed before me this _____________day of___________________________20______.

(Notary Seal)

___________________________________________________ Notary Public My commission expires:________________________________

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