Financial Oversight & Special Entities Division

Full name and address of the PEO under which this biographical statement is being required.

In connection with the above-named entity, I herewith make representations and supply information about myself as hereinafter set forth. (Attach addendum or separate sheet if space here is insufficient to answer any question fully.)

IF ANSWER IS 'NO', 'NONE' or 'NOT APPLICABLE', SO STATE

Please complete the schedule below pertaining to the schools you have attended starting with high school. Begin with the most recent and include all schooling, even if you did not graduate.

Other Training / Education Schedule

List memberships in any professional societies and associations:

Please complete the schedule below pertaining to past employment accounting for all periods of time for the past twenty (20) years, whether compensated or otherwise (up to and including present jobs, positions, partnerships, owner of an entity, administrator, manager, operator, directorates, or officerships). Please list the most recent first. It is only necessary to provide telephone numbers and supervisory information for the past ten (10) years.

Employment Information (continued)

List any professional, occupational, and vocational licenses (including licenses to sell securities) issued by any public or governmental licensing agency, regulatory authority or licensing authority that you presently hold or have held in the past:

In responding to the following, if the record has been sealed or expunged, and the applicant has personally verified that the record was sealed or expunged, an applicant may respond "NO" to the question. If the applicant answers "YES" to any question, attach an addendum explaining the details and circumstances (including location, license number, date, disposition, etc.). If the applicant has any doubt about the accuracy of an answer, the question should be answered in the positive and an explanation provided.

1. Have you ever been refused an occupational, professional, or vocational license or permit by any regulatory authority, or any public administrative, or governmental licensing agency?
   Yes No
2. Has any occupational, professional, or vocational license or permit you hold or have held, been subject to any judicial, administrative, regulatory, or disciplinary action?
   Yes No
3. Is any occupational, professional, or vocational license or permit that you hold under investigation or pending disciplinary action in any state?
   Yes No
4. Have you ever been placed on probation or had a fine levied against you or your occupational, professional, or vocational license or permit in any judicial, administrative, regulatory, or disciplinary action?
   Yes No
5. Have you ever been charged with, or indicted for, any criminal offense(s) other than civil traffic offenses?
   Yes No
6. Have you ever pled guilty, or nolo contendere, or been convicted of, any criminal offense(s) other than civil traffic offenses?
   Yes No
7. Have you ever had 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(s) other than civil traffic offenses?
   Yes No
8. Have you ever been adjudged a bankrupt?
   Yes No
9. Have you ever been a defendant in a military court martial?
   Yes No
10. Are you in arrears on any taxes or guaranteed student loans?
    Yes No
11. Have you ever had a lien or foreclosure action filed against you or any entity while you were associated with that entity?
    Yes No
12. Have you ever been, within the past ten (10) years, a party to any civil action involving dishonesty, breach of trust, or a financial dispute?
    Yes No
13. To your knowledge has any company or entity for which you are or were an officer or director, trustee, investment committee member, key management employee or controlling stockholder, had any of the following events occur while you served in such capacity?

    When responding to questions (b), (c) and (d) affiant should also include any events within twelve (12) months after his or her departure from the entity.

    a. Been refused a permit, license, or certificate of authority by any regulatory authority, or governmental licensing agency?

    Yes No

    b. Had its permit, license, or certificate of authority suspended, revoked, cancelled, non-renewed, or subjected to any judicial, administrative, regulatory, or disciplinary action (including rehabilitation, liquidation, receivership, conservatorship, federal bankruptcy proceeding, state insolvency, supervision or any other similar proceeding)?

    Yes No

    c. Been placed on probation or had a fine levied against it or against its permit, license, or certificate of authority in any civil, criminal, administrative, regulatory, or disciplinary action?

    Yes No

    d. Voluntarily surrendered its permit, license, registration, or certificate of authority in lieu of further investigation?

    Yes No
14. Have you ever been an officer of an entity that currently has outstanding delinquent obligations for federal or state payroll taxes, health insurance premiums, or workers' compensation premiums?

    Yes No
15. Regulated organizations you control

    List any organization that is regulated by either an insurance authority or a professional employer organization authority, if you have direct or indirect control over it. “Control” means having the power to guide how a business or entity is managed, whether that’s through owning voting shares, having a contract (except for basic goods or services), or holding an official position within the organization. If someone owns or controls at least 10% of voting shares (either directly or indirectly) that person is presumed to have control over the organization.

    List the organization(s) and provide the requested details (entity name, regulator/authority, how you control it, and ownership % if applicable):

    Is any of the stock of any of the above entities pledged or hypothecated in any way?

    Yes No
16. Stock ownership disclosure

    Do [Will] you or members of your immediate family individually or cumulatively subscribe to or own, beneficially or of record, ten percent (10%) or more of the outstanding shares of stock of any entity subject to regulation by an insurance regulatory authority or professional employer organization regulatory authority, or its affiliates?

    An "affiliate" of, or person "affiliated" with, a specific person, is a person that directly, or indirectly through one or more intermediaries, controls, or is controlled by, or is under common control with, the person specified. If the answer is "Yes", please identify below the entity or entities in which the cumulative stock holdings represent 10% or more of the outstanding voting securities.

    Yes No If yes, identify the entity or entities:

    Is any of the stock of any of the above entities pledged or hypothecated in any way?

    Yes No

I, , do hereby state and certify 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.
• I am at least 18 years of age.
• I have a personal history of honesty, trustworthiness, fairness, a good reputation for fair dealings, and respect for the rights of others and for state and federal laws.
• I have adequate management competence to serve as a controlling person for the herein named Applicant /PEO.

I authorize the Commissioner, his agent, assigns, contractors, and/or staff to conduct a background investigation to verify the information contained herein. I understand that such background investigation may include, but not be limited to, a formal background check, directly contacting any appropriate entities, or other methods deemed necessary.

I further authorize any entities contacted as a result of the above referenced background investigation to release the requested information to the background investigator and/or the Commissioner, and hold them harmless for the release of this information subject to this release authorization. A photocopy of this release shall be valid and have the same force and effect as the signed original.

IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed in their names and behalf by their duly authorized officers this day of , .

NOTARY PUBLIC

(Seal)