Application For Certificate Of Authority (Motor Club) Page 13
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
1514.
Do [Will] you or members of your immediate family individually or cumulatively subscribe to or own,
beneficially or of record, 10% or more of the outstanding shares of stock of any insurance entity
subject to regulation by an insurance regulatory authority, or its affiliates? An “affiliate” of, or person
“affiliated” with, a specific person, is a person that directly, or indirectly through one or more
intermediaries, controls, or is controlled by, or is under common control with, the person specified. If
the answer is “Yes”, please identify the company or companies in which the cumulative stock
holdings represent 10% or more of the outstanding voting securities.
____________________________________________________________________________________
____________________________________________________________________________________
If any of the shares of stock are pledged or hypothecated in any way, give details.
15.
Have you ever been adjudged a bankrupt? ___ If yes, provide details ___________________________
____________________________________________________________________________________
16.
To your knowledge has any company or entity for which you were an officer or director, trustee,
investment committee member, key management employee or controlling stockholder, had any of
the following events occur while you served in such capacity? If yes, please indicate and give
details. When responding to questions (b) and (c) affiant should also include any events within
twelve (12) months after his or her departure from the entity.
a. Been refused a permit, license, or certificate of authority by any regulatory authority, or
Governmental-licensing agency? ______________________________________________________
b. Had its permit, license, or certificate of authority suspended, revoked, canceled, non-renewed,
or subjected to any judicial, administrative, regulatory, or disciplinary action (including
rehabilitation, liquidation, receivership, conservatorship, federal bankruptcy proceeding, state
insolvency, supervision or any other similar proceeding)? ___________________________________
_________________________________________________________________________________
c. Been placed on probation or had a fine levied against it or against its permit, license, or
certificate of authority in any civil, criminal, administrative, regulatory, or disciplinary action? ________
Note:
If an affiant has any doubt about the accuracy of an answer, the question should be
answered in the positive and an explanation provided.
Dated and signed this _______ day of _____ 20
at ____________________ I hereby certify
under penalty of perjury that I am acting on my own behalf, and that the foregoing statements are
true and correct to the best of my knowledge and belief.
_________________________________________
________________________________
(Signature of Affiant)
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Application For Certificate Of Authority For Foreign Limited Liability Company - Secretary Of State
Legal
Application For Certificate Of Authority For Foreign Limited Liability Company - Wyoming Secretary Of State
Legal
Application For Certificate Of Authorization For Corporate Limited Liability Company (llc), Or Limited Liability Partnership (llp) Practice Form 2000
Legal
Application For Certificate Of Authority For Foreign Limited Liability Partnership, Form Ra-1 - Registered Agent Written Consent
Legal
Application For Certificate Of Authority For Foreign Non-profit Corporation/form Ra-1 - Registered Agent Written Consent
Legal
Application For Certificate Of Authority/affidavit Of Acceptance Of Appointment By Designated Initial Registered Agent
Legal
Related Categories
Parent category: Financial