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Vermont Captive Insurance Biographical Affidavit Form

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Vermont Captive Insurance Biographical Affidavit Form
Vermont Captive Insurance Biographical Affidavit Form
Vermont Department of Financial Regulation 89 Main Street, Montpelier, Vermont 05620-3101 1/3/2013
_____________________________________________________________________________________
DEPARTMENT OF FINANCIAL REGULATION
CAPTIVE INSURANCE
BIOGRAPHICAL AFFIDAVIT
To the extent permitted by law, this affidavit will be kept confidential by the state insurance regulatory authority.
Full name and address of the present or proposed Captive Insurance Company under which this biographical
statement is being required ________________________________________________________________________
_______________________________________________________________________________________________
In connection with the above named company, I herewith make representations and supply information about myself
as hereinafter set forth. ATTACH ADDITIONAL PAGES IF SPACE PROVIDED IS INSUFFIENT TO FULLY
ANSWER ANY QUESTION.
1. Affiant’s Full Name (Initials not acceptable) _______________________________________________________
Maiden Name (if applicable) ___________________________________________________________________
Name of Spouse (if applicable) _________________________________________________________________
2. Affiant’s Social Security Number __________________ Date of Birth (MM/DD/YY) _________________
Place of Birth (City, State/Province, Country) ______________________________________________________
3. Have you ever used any other name including nickname, maiden name or aliases If yes, give the reason and
provide the full name(s) and date(s) used. Yes No
Date(s) Used (MM/YY) Name(s) Reason(s)
______ to ______ _____________________ __________________________________________
______ to ______ _____________________ __________________________________________
4. Are you a citizen of the United States Yes No
Are you a citizen of another country Yes No
If yes, identify the country _________________________
Government Identification Number if not a U.S. Citizen _____________________________________________
5. Education and Training:
College/University City/State Dates Attended Degree Obtained
______________________ _________________________ ________________ _________________
Vermont Captive Insurance Biographical Affidavit Form
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