Del. Admin. Code tit. 18, 2000, 2001, STATE OF DELAWARE-INSURANCE DEPARTMENT, exh. C
INSURANCE DEPARTMENT
STATE OF DELAWARE
1351 WEST NORTH ST., SUITE 101
DOVER, DE 19904
BIOGRAPHICAL QUESTIONNAIRE FOR PREMIUM FINANCE COMPANIES
Company Name: _________________________________________
Office Held: _________________________________________
Individual's Name: _________________________________________
Date of Birth: ______________________ Place of Birth: _____________________
Current Residential Address: _________________________________________
Current Business Address: _________________________________________
Residential Address for Past Five Years: ________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
Education (Beyond High School):
_______________________________________________________
Employment History. (Beginning with current employer, trace back complete history. Show dates of employment, name and address of company, position held, and duties.)
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
List any other companies which you now serve, or within the past five years have served, as either an officer or director. (List company, position and dates.)
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Have you ever been charged with a criminal violation (other than a traffic offense) at any time? If "yes," provide complete details.
___________________________________________________________________
___________________________________________________________________
Have you ever held any other license (except a driver's license)
_ YES _ NO
If "yes," provide details as to any such license which was ever suspended, revoked, or renewal refused.
__________________________________________________________________
__________________________________________________________________
Have you ever been charged by any regulatory agency, whether City, County, State or Federal, with having violated any laws, rules or regulations or has any company been so charged, allegedly as a result of any action or conduct on you part?
_ YES _ NO
If "yes," as to either, submit full details including disposition of charge.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Date: _____________________ Signature ______________________________
State of_______________)
ss
County_______________)
On the ____________day of ________, 20__, before me, a Notary Public in and for the State and County aforesaid, personally appeared ________________________to me known to be the individual described in and who executed the foregoing and did make oath in due form of law that the matters and facts contained in the foregoing resume are true and correct.
____________________________
Notary Public
PF-3
Delaware
Del. Admin. Code tit. 18, 2000, 2001, STATE OF DELAWARE-INSURANCE DEPARTMENT, exh. C