Biographical Statement And Affidavit {SI-27}

FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION BUREAU OF MONITORING AND AUDIT 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 _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ FORM DFS-F2-SI-27 (8/2009) Rule 69L-5.229, F.A.C. Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 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 _________________________________________________________________________________________________________ _______________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ No May present employer be contacted? Yes 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 No Department of Financial Services? Yes (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 No entity? Yes 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)______________________________________