Application For Certificate Of Authority (Motor Club) (Page 12 of 15) in pdf

c. Been placed on probation or had a fine levied against you or your occupational,

professional, or vocational license or permit in any judicial, administrative, regulatory, or

disciplinary action? _________________________________________________________________

_________________________________________________________________________________________

d. Been charged with, or indicted for, any criminal offense(s) other than civil traffic offenses? _________

e. Pled guilty, or nolo contendere, or been convicted of, any criminal offense(s) other than civil

traffic offenses?

_________________________________________________________________________________

Had adjudication of guilt withheld, had a sentence imposed or suspended, had pronouncement

of a sentence suspended, or been pardoned, fined, or placed on probation, for any criminal

offense(s) other than civil traffic offenses? _______________________________________________

g. Been subject to a cease and desist letter or order, or enjoined, either temporarily or

permanently, in any judicial, administrative, regulatory, or disciplinary action, from violating any

federal, state law or law of another country regulating the business of insurance, securities or

banking, or from carrying out any particular practice or practices in the course of the business of

insurance, securities or banking? ______________________________________________________

_________________________________________________________________________________

h. Been, within the last ten (10) years, a party to any civil action involving dishonesty, breach of

trust, or a financial dispute? __________________________________________________________

Had a finding made by the Comptroller of any state or the Federal Government that you have

violated any provisions of small loan laws, banking or trust company laws, or credit union laws,

or that you have violated any rule or regulation lawfully made by the Comptroller of any state or

the Federal Government? ____________________________________________________________

Had a lien or foreclosure action filed against you or any entity while you were associated with

that entity?

_________________________________________________________________________________

If the response to any question above is answered “Yes”, please provide details including dates,

locations, disposition, etc. Attach a copy of the complaint and filed adjudication or settlement as

appropriate.

____________________________________________________________________________________

13.

List any insurance entity subject to regulation by an insurance regulatory authority that you control

directly or indirectly. The term “control” (including the terms “controlling,” “controlled by” and “under

common control with”) means the possession, direct or indirect, of the power to direct or cause the

direction of the management and policies of a person, whether through the ownership of voting

securities, by contract other than a commercial contract for goods or non-management services, or

otherwise, unless the power is the result of an official position with or corporate office held by the

person. Control shall be presumed to exist if any person, directly or indirectly, owns, controls, holds

with the power to vote, or holds proxies representing, ten percent (10%) or more of the voting

securities of any other person.

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

____________________________________________________________________________________

Application For Certificate Of Authority (Motor Club) Page 12