Form L-107 - Affidavit Of Managing General Agent (Page 2 of 2) in pdf

CONTINUED FROM THE REVERSE

SECTION D

1. Did the MGA named in Section B produce and underwrite

insurance anywhere in the United States for the insurer named in

Transaction

Section A during the preceding calendar year?

Yes

Volume

2. What year was the PRECEDING calendar year?

____________

3. If the answer to D.1 is YES, enter the amount of total gross direct

written premium produced and underwritten by the MGA for the

Insurer during the PRECEDING calendar year.

If the answer to D.1 is NO, enter the amount of total gross direct

written premium reasonably estimated to be produced and

underwritten by the MGA for the Insurer during the CURRENT

calendar year.

$________________

4. If the answer to D.1 is YES, enter the amount of "total monies

handled" (gross written premium less gross return premium) by

the MGA for the Insurer during the PRECEDING calendar year.

If the answer to D.1 is NO, enter the amount of total monies

reasonably estimated to be handled by the MGA for the Insurer

during the CURRENT calendar year.

$________________

5. If the answer to D.1 is YES, enter the policyholder surplus for the

Insurer during the PRECEDING calendar year as reported in the

Insurer's Annual Statement.

If the answer to D.1 is NO, enter the estimated policyholder

$________________

surplus for the Insurer for the CURRENT calendar year.

6. Enter the ratio (with two decimal points - ##.##%) of gross direct

written premium to policyholder surplus (A5 divided by A3).

______________%

SECTION E

The total amount of the required deposit shall be 10% of the amount

in Section D.4, except no deposit may be less than $50,000 or more

Deposit

than $100,000.

AFFIDAVIT

STATE OF ________________ )

)

COUNTY OF _______________)

I, _____________________________________, being duly sworn, depose and say that the above statement is

true and correct to the best of my knowledge and belief.

_____________________________________________

___________________________________________

PRINTED NAME AND TITLE OF INSURANCE COMPANY OFFICER

SIGNATURE OF INSURANCE COMPANY OFFICER

_____________________________________________

___________________________________________

INSURANCE COMPANY TELEPHONE NUMBER

INSURANCE COMPANY FAX NUMBER

Subscribed and sworn to before me this __________ day of ___________________________ in the year __________,

_______________________________________

(Notary Seal)

NOTARY PUBLIC

My commission expires: ____________________

Page 2 of 2

Form L-107 (Rev. 12/2001)

Form L-107 - Affidavit Of Managing General Agent Page 2

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