Form Fin311 - Biographical Affidavit
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3FIN311 | 0315
BIOGRAPHICAL AFFIDAVIT
(Print or Type)
Full Name and Address of Company/HMO (Do Not Use Group Names): _________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
In connection with the above-named company/HMO, I herewith make representations and supply information about myself as
hereinafter set forth. (Attach addendum or separate sheet if space hereon is insufficient to answer any questions fully.)
IF ANSWER IS "NO" OR "NONE", SO STATE.
1. Affiant's Full Name (Initials Not Acceptable): ____________________________________________________________
2. a. Have you ever had your name changed? ____ If yes, give reason for the change: _____________________________
_______________________________________________________________________________________________
b. Maiden Name (if female) __________________________________________________________________________
c. Other names used at any time ______________________________________________________________________
3. Affiant's Social Security Number*: _____________________________________________________________________
4. Date and Place of Birth: _____________________________________________________________________________
5. Affiant's Business Address: ___________________________________________________________________________
Business Telephone: ________________________________________________________________________________
6. List your residences for the last ten (10) years starting with your current address, giving:
DATES
ADDRESS
CITY AND STATE
ZIP CODE
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
7. Education: Dates, Names, Locations and Degrees
College ___________________________________________________________________________________________
_________________________________________________________________________________________________
Graduate Studies __________________________________________________________________________________
_________________________________________________________________________________________________
Others ___________________________________________________________________________________________
_________________________________________________________________________________________________
8. List Membership in Professional Societies and Associations: ________________________________________________
_________________________________________________________________________________________________
9. Present or Proposed Position with the Applicant Company/HMO: ___________________________________________
_________________________________________________________________________________________________
*
Refer to P.L. 93-579, Disclosure of Social Security Account Number.
Texas Department of Insurance |
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