Application For Certificate Of Authority (Motor Club) Page 14
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15BIOGRAPHICAL AFFIDAVIT
Supplemental Information
(Print or Type)
To the extent permitted by law, this affidavit will be kept confidential by the state insurance regulatory
authority.
Full Name, Address, and telephone number of the present or proposed entity under which this biographical
statement is being required (Do Not Use Group Names).
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
1.
a. Affiant’s Full Name (Initials Not Acceptable). ______________________________________________
b. Maiden Name (if applicable) __________________________________________________________
2.
Affiant’s Social Security Number __________________________________________________________
3.
Government Identification Number if not a U.S. Citizen ________________________________________
4.
Foreign Student ID# (if applicable) ________________________________________________________
5.
Date of Birth: (MM/DD/YY) _____________ Place of Birth: City _________________________________
State/Province _______________________ Country _________________________________________
6.
Name of Affiant’s Spouse (if applicable) ____________________________________________________
7.
List your residences for the last ten (10) years starting with your current address, giving:
Beginning/Ending
Dates
State/
(MM/YY)
Address
City
Province
Country
Postal Code
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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
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