Form E501ihcs - Insurance Holding Company System Officers And Directors List

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Department of Insurance
Applicant Name: __________________________________________________________
State of Arizona
DBA:
Financial Affairs Division
___________________________________________________________________
2910 NORTH 44TH STREET, SUITE 210
NAIC #: __________________________
Domicile: ___________________________
Phoenix, Arizona 85018-7256
FED ID #: __________________________
Telephone: (602) 912-8420
Telecopier: (602) 912-8421
INSURANCE HOLDING COMPANY SYSTEM OFFICERS AND DIRECTORS LIST
This form is required to be completed as part of your application or filing.
Although your Company may have already provided all or some of this information in another form, such as Biographical Affidavits, your completion of this form
will assist in the timely processing of your request.
The date of birth and Social Security Number information is requested to assure each individual’s identity and is not reproduced or disseminated from this
source.
Please use the following legend of two (2) character codes to identify titles.
DI
Director
CE
Chief Executive Officer
CF
Chief Financial Officer
MD
Medical Director
CB
Chairman of Board
PR
President
TR
Treasurer
MR
Medical Records
UCP Ultimate Controlling Person VP
Vice President
CO
Controller
IO
Investment Officer
SC
Secretary
Provide name, firm and mail address for the following Contact Persons:
Control Type
Full Name and Firm
Complete Business Mail Address
Phone
A. Ultimate Controlling Person (Individual):
B. Ultimate Controlling Corporation:
C. Immediate Parent Corporation:
You may fill in the blanks on the reverse side for the required Officers and Directors information or attach your own list prepared in identical format.
Signature of Preparer
Date Prepared
E501IHCS (06/00)
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