Form Dfs-F2-Si-27 - Biographical Statement And Affidavit - 2009 Page 4
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521.
(a) For the purpose of this question, if you hold or have held any of the following positions with an entity, please
indicate below.
1. Incorporator
Yes
No
2. Administrator
Yes
No
3. Organizer
Yes
No
4. Subscriber of a corporation
Yes
No
5. Subscriber to a reciprocal agreement of indemnity
Yes
No
6. Subscriber of a limited reciprocal
Yes
No
7. Director
Yes
No
8. Officer
Yes
No
9. Manager or operator
Yes
No
10. Trustee
Yes
No
11. Owner, if not a corporation
Yes
No
12. Sole proprietor
Yes
No
13. Joint venturer
Yes
No
14. Partner, including all general and limited partners of a limited partnership.
Yes
No
15. Stockholder owning or holding five (5) percent or more of the
outstanding stock of a stock corporation
Yes
No
16. Member of a non-stock corporation
Yes
No
17. Person associated or to be associated with the formation or financing of
an underwriting member on an Insurance Exchange in any state or country
Yes
No
18. Attorney in fact for a reciprocal insurer/company or a limited reciprocal
insurer/company, if the attorney in fact is an individual
Yes
No
19. Any position listed in this subparagraph (a) held in an entity serving as
attorney in fact for a reciprocal insurer/company or a limited reciprocal insurer/
company, if the entity serving as attorney in fact is not an individual
Yes
No
20. Any position listed in this subparagraph (a) held in an incorporated or
unincorporated association
Yes
No
21. Any other position where the person filling the position performs any
duties similar to those duties performed by persons in the above mentioned positions
Yes
No
(b) Has any entity while you were associated with that entity or within twelve (12) months after you left:
1. Been refused a permit, license, or certificate of authority by any
regulatory authority, or governmental licensing agency?
Yes
No
2. Had its permit, license, or certificate of authority suspended, revoked,
Yes
No
cancelled, non-renewed, or subjected to any judicial, administrative, regulatory, or disciplinary action?
3. Been placed on probation or had a fine levied against it or against its
Yes
No
license, or certificate of authority in any judicial, administrative, regulatory, or disciplinary action?
4. Been charged with, or indicted for any criminal offense?
Yes
No
5. Pled guilty to, or nolo contendere to, or been convicted of any criminal
Yes
No
offense?
FORM DFS-F2-SI-27 (8/2009)
Page 4 of 5
Rule 69L-5.229, F.A.C.
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