Have you personally or a firm that you exercised management control over or owned 10% or more of the
securities of a company that failed in business, made a compromise with creditors, filed a bankruptcy petition
or was declared bankrupt?
Has any State Insurance Department, any other State or Federal Regulatory Agency or any Self Regulatory Organization ever:
A. entered an order against you relative to a violation of insurance or investment-related regulations or statutes?
B. fined, denied, suspended or revoked your license or registration?
Has a bonding company denied, paid out or revoked a bond for you?
Have you been discharged or permitted to resign, or otherwise had your relationship with a company terminated, because
you were accused of violating investment related statutes, regulatory rules or industry standard of conduct, fraud or
wrongful taking of property?
Have you ever been convicted of, or plead guilty or nolo contendere ("no contest") to:
A. a felony or misdemeanor involving: insurance, investments, or a related business, fraud, theft, breach of trust,
false statements or omissions, wrongful taking of property, bribery, forgery, counterfeiting or extortion?
B. any other felony?
Do you have any debit balances with another insurance agency, or unsatisfied judgements or liens, including tax liens,
against you? If yes, provide details, supporting documentation including dollar amount outstanding, and schedule of
repayment plan or final disposition.
Are you an employee, officer, director or agent of any bank, savings and loan association, mortgage company,
investment adviser firm, insurance company/agency, broker/dealer, or other lending or financial institution?
Are you now the subject of any complaint, investigation, or proceeding that could result in a "yes" answer to
the above questions?