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Puerto Rico Biographical Affidavit Form

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Puerto Rico Biographical Affidavit Form
Puerto Rico Biographical Affidavit Form
Office of the Commissioner of Insurance FORM CIS 005 Page 1 of 5
Commonwealth of Puerto Rico
P.O. Box 8330
San Juan, Puerto Rico 00910-8330
COMMONWEALTH OF PUERTO RICO
OFFICE OF THE COMMISSIONER OF INSURANCE
BIOGRAPHICAL AFFIDAVIT
1. International Insurer’s Name: __________________________________________
2. Affiant’s Full Name (Initials are Not Acceptable): _________________________
_____________________________________________________________________
3. Have you ever used any other name including a Maiden Name ___________
If yes, explain: _______________________________________________________
_____________________________________________________________________
4. Social Security No.: ___________________________________________________
5. Date of Birth: ______________ Birth Place: _________________________
6. Business Address: ___________________________________________________
_____________________________________________________________________
_____________________________________________________________________
7. Business Phone: _____________________________________________________
8. List your residence for the last 5 years starting with the current address:
DATES OF RESIDENCE ADDRESS
_______________________ ____________________________________
_______________________ ____________________________________
_______________________ ____________________________________
_______________________ ____________________________________
9. Education (Specify Dates, Institutions and Degrees):
DATES INSTITUTIONS DEGREES
___________ ____________________________ ________________________
___________ ____________________________ ________________________
___________ ____________________________ ________________________
___________ ____________________________ ________________________
Puerto Rico Biographical Affidavit Form
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