Fillable Form Fin311 - Biographical Affidavit (Page 2 of 3) in pdf

FIN311 | 0315

10. List complete employment record (up to and including present jobs, positions, directorates or officerships) for the past

twenty (20) years:

DATES

EMPLOYER AND ADDRESS

TITLE

_________________________________________________________________________________________________

11. Present employer may be contacted:

☐ Yes

☐ No

Former employers may be contacted:

☐ Yes

☐ No

12. a. Have you ever been in a position which required a fidelity bond?____________ If any claims were made on the bond,

give details: _______________________________________________________________________________________

b. Have you ever been denied an individual or position schedule fidelity bond, or had a bond cancelled or revoked? __

If yes, give details: __________________________________________________________________________________

_________________________________________________________________________________________________

13. List any professional, occupational or vocational licenses issued by any public or governmental licensing agency or

regulatory authority which you presently hold or have held in the past. (State date license was issued, issuer of license,

date terminated, reasons for termination): _____________________________________________________________

_________________________________________________________________________________________________

14. During the last ten (10) years, have you ever been refused a professional, occupational or vocational license by any public

or governmental licensing agency or regulatory authority, or has such license held by you ever been suspended or

revoked?_______ If yes, give details: __________________________________________________________________

_________________________________________________________________________________________________

15. List any insurers which you control directly or indirectly or own legally or beneficially 10% or more of the outstanding stock

(in voting power): __________________________________________________________________________________

_________________________________________________________________________________________________

If any of the stock is pledged or hypothecated in any way, give details: _______________________________________

_________________________________________________________________________________________________

16. Will you or members of your immediate family subscribe to or own, beneficially or of record, shares of stock of the

applicant insurance company/HMO or its affiliates?__________ If any of the shares of stock are pledged or hypothecated

in any way, give details:

_________________________________________________________________________________________________

17. Have you ever been adjudged a bankruptcy? ____________________________________________________________

18. a. Have you ever been convicted or had a sentence imposed or suspended or had pronouncement of a sentence suspended

or been pardoned for conviction of or pleaded guilty or nolo contendere to any information or indictment charging any

felony, or charging a misdemeanor involving embezzlement, theft, larceny, or mail fraud, or charging a violation of any

corporate securities statute or any insurance law, or have you been the subject of any disciplinary proceedings of any

federal or state regulatory agency?__________________

If yes, give details: __________________________________________________________________________________

_________________________________________________________________________________________________

Texas Department of Insurance |

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Form Fin311 - Biographical Affidavit Page 2

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