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Form E278 - Certificate Of Disclosure - Company Authorization - Department Of Insurance Of State Of Arizona

Department of Insurance

State of Arizona

Financial Affairs Division

2910 NORTH 44TH STREET, SUITE 210

Phoenix, Arizona 85018-7256

Telephone: (602) 912-8420

Telecopier: (602) 912-8421

CERTIFICATE OF DISCLOSURE - COMPANY AUTHORIZATION

NAIC NUMBER

State of Incorporation

COMPLETE APPLICANT COMPANY NAME

COMPLETE REPORTING COMPANY NAME

HOME OFFICE ADDRESS (STREET)

CITY, STATE AND ZIP CODE

PART A:

Have any persons serving either by election or appointment as officers, directors, incorporators as well as persons

controlling or holding more than ten percent (10%) of the issued and outstanding common shares or ten percent

(10%) of any other proprietary, beneficial or membership interest in the corporation:

Been convicted of a felony involving a transaction in securities, insurance consumer fraud or antitrust in any

state or federal jurisdiction within the seven-year period immediately preceding the execution of this certificate?

Been convicted of a felony, the essential elements of which consisted of fraud, misrepresentation,theft by false

premises or restraining the trade or monopoly in any state or federal jurisdiction within the seven-year period

immediately preceding the execution of this certificate?

Been or are subject to an injunction, judgement, decree or permanent order of any state or federal court entered

within the seven-year period immediately preceding the execution of this certificate where such injunction,

judgement decree or permanent order:

Involved the violation of fraud or registration provisions of the securities laws of that jurisdiction; or

Involved the violation of the consumer fraud laws of that jurisdiction; or

Involved the violation of the antitrust or restraint of trade laws of that jurisdiction; or

Involved the violation of the insurance laws of that jurisdiction?

ANSWER

YES

(MUST BE ANSWERED)

If your answer to any of Items A.1 through A.3 is "YES," the following information for each person must be

attached:

Full name and prior names used.

Date and location of birth.

Full birth name.

Social Security number.

Present home address.

The nature and description of each conviction or

judicial action, the date and location, the court and

Prior addresses (for immediate preceding

public agency involved and the file or case number of

seven-year period).

the case.

Form E278 (Rev. 06/00)

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Form E278 - Certificate Of Disclosure - Company Authorization - Department Of Insurance Of State Of Arizona

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