Fin531 Biographical Form And Certification Of License Qualification Following A Change Of Control - Texas Department Of Insurance Page 2

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Resident

Non-Resident

□

Fingerprints / L1 enrollment Services receipt attached.

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Individual has an active TDI license number

and fingerprints previously submitted.

□

Fingerprints previously submitted (date

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The above entity and/or the individual is currently licensed in resident state with a license similar to the license applied

for on this application.

INDIVIDUAL’S LEGAL NAME

TITLE

SOCIAL SECURITY NUMBER

DATE OF BIRTH

MAILING ADDRESS

CITY

STATE / ZIP CODE

Resident

Non-Resident

□

Fingerprints/ IdentoGO by MorphoTrust USA receipt attached.

□

Individual has an active TDI license number

□

Fingerprints previously submitted (date

□

The above entity and/or the individual is currently licensed in resident state with a license similar to the license applied

for on this application

Part 2 – Change of Control

2A. Detail any change of control to any entity that directly controls the licensed agency. Disclose all entity and individual control relationships affecting

the agency up to the ultimate controlling individual or entity.

DIRECT OWNER OF TDI LICENSED ENTITY

FEIN

CONTACT PHONE NUMBER

ADDRESS/ PHYSICAL LOCATION

CITY

STATE/ZIP CODE

DIRECT OWNER’S OFFICERS / DIRECTORS

OFFICER / DIRECTOR

2B. Attach to this form a document which discloses all entity and individual control relationships affecting the agency up to the ultimate controlling

individual or entity. This disclosure may be in the form of an organization chart naming the entities and individuals showing their relationship to the

licensed entity. Provide the name, FEIN, and mailing address of each entity listed on the attached document.

Part 3 – Disassociation / Removal

List each individual to be disassociated from control of the licensed TDI agency. Copy this form and attach additional pages as needed.

INDIVIDUAL'S FULL LEGAL NAME

TITLE (AS RELATED TO THE ENTITY)

INDIVIDUAL’S FULL LEGAL NAME

TITLE (AS RELATED TO THE ENTITY)

INDIVIDUAL’S FULL LEGAL NAME

TITLE (AS RELATED TO THE ENTITY)

FIN531 Rev. 01/15

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