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Item 8 Organizational Affidavit 8 - California
| Item 8 Organizational Affidavit Form. This is a California form and can be used in Department Of Insurance Statewide . |
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CALIFORNIA CERTIFICATE OF AUTHORITY APPLICATION ITEM #8 ORGANIZATIONAL AFFIDAVIT See affidavit instructions before completing affidavit. 1. Name of applicant (and intended Fictitious Business name, if any): ___________________________ A. B. C. D. E. F. G. 2. Type of application: _________________________________ Reason for application: ___________________________________________________________ Statutory home address of applicant: ________________________________________________ Primary location of books and records for applicant: ___________________________________ Applicant's state of domicile: __________________________ NAIC number of applicant (including group number, if any): ____________________________ Federal employer identification number of applicant: ___________________________________ If applicant is part of a holding system, or has subsidiaries, or affiliates, provide a detailed organizational chart. Place an asterisk * by all insurers holding a Certificate of Authority in California. Name of applicant's ultimate controlling parent: A. Statutory home address of applicant's ultimate controlling parent: _______________________________________________________________________________ B. Primary location of books and records for applicant's ultimate controlling parent: _______________________________________________________________________________ C. Ultimate controlling parent's state of domicile: ________________________________________ 3. 4. List names and titles of each of the applicant's Officers and Directors as shown in the format below. Name (Last, First, Middle) Title ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 08/03 Doc. form08.wpd American LegalNet, Inc. www.FormsWorkFlow.com CALIFORNIA CERTIFICATE OF AUTHORITY APPLICATION A. Under "Name", show name as follows: Last Name, First Name, Middle Name. If there is no Middle Name, indicate (NMN). If there is an Initial Only, indicate (IO), following the initial. Under "Title(s)", indicate the title of each officer/director. Do Not abbreviate. B. 5. List the names of all entities and/or individuals who hold ten (10) percent or more of Applicant's capital stock utilizing the format below. Name Percent of Stock ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ A. Under "Name", if the holder is an entity, show the name of the Corporation, and DBA. Under "Name", if the holder is an individual, show the name as follows: Last Name, First Name, Middle Name. If there is no Middle Name, indicate (NMN). If there is an Initial Only, indicate (IO), following the initial. Under "Percent of Stock", show the percent of stock held by each entity or person. B. 6. Provide the names and titles of all individuals who are officers and/or directors of applicant's ultimate controlling parent, utilizing the following format. Name Title ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ A. Under "Name", show name as follows: Last Name, First Name, Middle Name. If there is no Middle Name, indicate (NMN). If there is an Initial Only, indictae (IO), following the Initial. Under "Title", indicate the title of each officer/director. DO NOT abbreviate. B. 7. Please provide the names of all entities and/or individuals who hold ten (10) percent or more of the capital stock of Applicant's ultimate controlling parent, utilizing the following format. (If any of these individuals have not previously submitted an Individual Affidavit they are required to do so.) Name Percent of Stock ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com CALIFORNIA CERTIFICATE OF AUTHORITY APPLICATION A. Under "Name", if the holder is a corporation, show the name of the corporation, and DBA. If the holder is an individual, show the name as follows: Last Name, First Name, Middle Name. If there is no Middle Name, indicate (NMN). If there is an Initial Only, indicate (IO). B. 8. Under "Percent of Stock", show the percent of stock held by each entity or person. Provide a list, and certified copies of all criminal, civil, regulatory and administrative action(s) taken against applicant and/or applicant's ultimate controlling parent by any governmental body including actions outside the United States, (within the last ten (10) years) utilizing the following format: Date: Reason for Action: Show exact date of action. Example: 2-10-82. Be specific. Provide code sections if applicable. Give a brief summary of the alleged violation. Government Body Taking Action: Be specific. Do not abbreviate. Include name, and full address of agency, including zip code. Case Number (Or Other Reference): Include both the agency and court case/reference number. Results of Action: 9. Give a brief summary of the results of the action. Provide the names, ficticious names, and complete addresses of all Managing General Agents utilized by applicant. If the Managing General Agent is a corporation, provide the full names of all officers, directors, producers, and stockholders who hold ten (10) percent or more of the capital stock. If the Managing General Agent is an individual utilizing a fictitious name, provide the full name of the individual and the fictitious name. Indicate in which states the Managing General Agent is acting on behalf of the applicant. Indicate the type(s) of license(s) the Managing General Agent holds in each state. __________________________________________________________________
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