1. 1. Affiant's Full Name: ____________________
2. 2. Aliases used at any time: ____________________
3. 3. Born ____________________ (Date) at ____________________(Place)
4. 4. Color of Hair ____________________, Eyes ____________________, Height____________________

5. 5. Schooling (check those applicable)

   High School

   College

   Graduate or

   Professional

   Degrees (list)

6. 6. Member of Professional Societies or Associations. List:

7. 7. I control directly or indirectly, or own legally or beneficially 10% or more of the outstanding capital stock (in voting power) of, the following insurers:

   1. 8. Present Chief Occupation.

      Position or Title:

      Employer:Name

      Address

      How long in this position?

      How long with this employer?

      Where?

8. 9. Other jobs, positions, directorates, or officership concurrently held at present:

   1. 11. If the answers to the foregoing do not show your complete experience in or with the insurance industry, detail the remainder on the back of this page. List names and addresses of insurance employers and positions held and approximate dates.

   10.Others held in the past:

9. 12. For the last 10 years, I have lived at the following address or addresses:
10. 13. I have never been adjudicated a bankrupt, except as follows:
11. 14. I have never been convicted or had a sentence imposed suspended or had pronouncement of a sentence suspended or been pardoned for conviction of, or pleaded guilty of or nole contendere to an information or an indictment charging a felony for embezzlement, theft or larceny, mail fraud, or violating any corporate securities statute or any insurance law, except as follows:
12. 15. I presently hold or have held in the past the following professional, occupational and vocational licenses issued by public or governmental licensing agencies or authorities (state date license issued, issuer of license, date terminated, reason for termination)
13. 16. During the last 10 years I have neither been refused a professional, occupational or vocational license by any public or governmental licensing agency or regulatory authority, nor has such a license held by me ever been suspended or revoked, except as follows:
14. 17. I have never been named defendant in a suit brought by any public or governmental licensing agency or regulatory authority for violation of or to prevent the violation of any securities or insurance law, except as follows:
15. 18. I have never been made the subject of a cease and desist order by any federal or state securities regulatory agency, except as follows:
16. 19. I have never been an officer, director, trustee, investment committee member, key employee or controlling stockholder of an insurer which, while I occupied any such position or capacity with respect to it, became insolvent or was placed in conservatorship, or was enjoined from or ordered to cease and desist from violating any securities or insurance law, except as follows:
17. 20. The certificate of authority or license to do business of any insurance company of which I was an officer or director or key management person has never been suspended or revoked while I occupied such position, except as follows:
18. 21. No insurer of which I was an officer, director or key management person at the time has ever been denied or refused a license or certificate of authority or withdrawn an application therefor, except as follows:

19. 22. (Complete for Permits only) The shares in the original issue (the subject of this organizational permit), subscribed for by me as a member of the group consisting of promoters, organizers, initial officers and directors, will be purchased with funds that are now, or will at the time of purchase be, my property, and no other person will have any legal or equitable interest in said shares, after purchase except as follows:

    ____________________

    (Signature of Affiant)

    NOTE: If this is executed in a state other than California, it is to be sworn to before a Notary Public and his official certificate attached hereto. If executed in California, affiant shall certify to the truth of the statements contained hereon and attached hereto, by completing and subscribing to the following:

    STATE OF CALIFORNIA

    )

    )

    ss

    COUNTY OF

    )

    I hereby certify under penalty of perjury that the foregoing statements are true and correct.

    __________

    (Signature of Affiant)

    Insurance Code Section 717, 718, 843.

The following affidavit will be required of the organizers, promoters, original officers and directors of all applicants for organizational permits, and may be required in the case of unseasoned applicants.

Permit____________________

or Admission ____________________

Name of Company applying for Permit or Certificate of Authority:

In connection with the application of the above named company to the California Insurance Commissioner for a permit or admission, I herewith make representations and supply information about myself as hereinafter set forth. I make these statements under oath. (Attach addenda on separate sheet if space hereon is insufficient to answer any question fully. If answer is “None” or “No exceptions,” so state.