Fin531 Biographical Form And Certification Of License Qualification Following A Change Of Control - Texas Department Of Insurance Page 3

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Part 4 – Notice About Certain Information Laws and Practices

The following notice must be distributed to all individuals listed on this form:

Notice About Certain Information Laws and Practices

Access and Correction of Personal Information - With few exceptions, you are entitled to be informed about the information

that TDI collects about you. Under Sections 552.022 and 552.023 of the Texas Government Code, you have the right to

review or receive copies of information about yourself, including private information. However, TDI may withhold

information for reasons other than to protect your right to privacy. Under Section 559.004 of the Texas Government Code,

you are entitled to request that TDI correct information that TDI has about you that is incorrect. For more information

about the procedure and costs for obtaining information from TDI or about the procedure for correcting information kept

by TDI, please contact the Agency Counsel Section of TDI’s Legal Program at AgencyCounsel@tdi.texas.gov or review TDI's

Corrections Procedures at

Part 5 – Attestation

A licensed officer, director or partner of the licensed entity must read and execute below.

I certify that I have personally and completely answered each of the questions herein and that I have attached to this form all information requested

and that these answers and attachments are true and correct to the best of my knowledge and belief. I further certify that I am aware of the provisions

of the Texas Insurance Code and the rules and regulations promulgated by the Texas Department of Insurance which relate to the license(s) held

and the grounds under which such license(s) may be suspended, revoked or non-renewed.

I further certify that each listed or named individual has, to the best of my knowledge and belief, received a true and correct copy of the disclosure

entitled Notice About Certain Information Laws and Practices.

I further certify that, to the best of my knowledge and belief, immediately following the changes disclosed in this document the agency will be able to

satisfy the requirements for issuance of the license to solicit the line or lines of insurance for which it is licensed.

I further certify that, to the best of my knowledge and belief, no individual listed in response to Part 1 of this document has had a license suspended or

revoked or been the subject of any other disciplinary action by a financial or insurance regulator of this state, another state, or the United States.

I further certify that to the best of my knowledge and belief, that no individual listed in response to Part 1 of this document has committed an act for

which a license may be denied under § 4005.101 of the Texas Insurance Code.

I acknowledge and understand that the officer(s), partners and director(s) of this entity have the duty to inform the Commissioner of Insurance

within thirty (30) days of any disciplinary action taken by a financial or insurance regulator of this state, another state, or the United States against the

licensed entity or any individual associated with the entity who is required to file biographical information with the Department.

I further acknowledge that the officer(s), partners and director(s) have the duty to update the information contained in the entity's license records,

including a change in address, and that failure to do so constitute grounds for revocation, or suspension of its insurance license(s).

SIGNATURE OF OFFICER OR PARTNER OF THE AGENCY

PRINT FULL LEGAL NAME OF SIGNING OFFICER OR PARTNER OF THE AGENCY

The State of

_________________________________,

County of _____________________________________, §

Before me, ____________________________________________, on this day personally appeared

( PRINT NAME OF NOTARY PUBLIC)

_______________________________________________________ ,

known to me (or proved to me

(PRINTED FULL NAME OF SIGNING INDIVIDUAL)

on the oath o