NJ Division of Insurance -

DEPARTMENT OF BANKING AND INSURANCE

LIFE AND HEALTH DIVISION

MANAGED CARE BUREAU
BIOGRAPHICAL AFFIDAVIT

Full name and Address of Entity (Do not use group name).

_________________________________________________________________

In connection with the above-named Arrangement, I herewith make representations and supply information about myself as hereinafter set forth. (Attach addendum or separate sheet if space hereon is insufficient to answer any question fully.) IF ANSWER IS "NO" OR "NONE", SO STATE. DO NOT LEAVE ANY QUESTIONS UNANSWERED.

1. Affiant's Full Name. ______________________________________________

_________________________________________________________________

2. a. Have you ever had your name changed? Yes

If yes, state the reason for the change.

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b. Other names used at any time. ______________________________________

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3. Date and Place of Birth. _____________________________________________

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4. Affiant's Business Address. _____________________________________________

______________________________________________________________________

Business Telephone Number: ___________________________________________

5. List your residence for the last ten (10) years starting with your current address, stating:

Date - Address - City/State

_______________________________________________________________________

6. Education: Dates, Names, Locations and Degrees

College ____________________________________________________________

__________________________________________________________________

Graduate Studies ___________________________________________________

__________________________________________________________________

Others ___________________________________________________________

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7. List memberships in Professional Societies/Association.

_________________________________________________________________________

8. Present or Proposed Position with the Applicant Entity.

_________________________________________________________________________

9. List complete employment record (up to and including present jobs, positions, directorates, or officership) for the past twenty- (20) years, stating:

Dates - Employer And Address - Title

_____________________________________________________________________________

10. Present employer may be contacted. Yes No

Former employers may be contacted. Yes No

11. a. Have you ever been in a position that required a fidelity bond? Yes

If any claims were made on the bond, state details. _________________________________

________________________________________________________________________

b. Have you ever been denied an individual or position schedule fidelity bond, or had a bond cancelled or revoked? Yes No

If yes, state details. _________________________________________________________

________________________________________________________________________

12. List any professional, occupational, and vocational licenses issued by any public or governmental licensing agency or regulatory authority which you presently hold or have held in the past (state date license issued, issuer of license, date terminated, reasons for termination).

_____________________________________________________________________________

13. During the last ten- (10) years, have you ever been refused a professional, occupational, or vocational license by any public or governmental licensing agency or regulatory authority, or has any such license held by you ever been suspended or revoked? Yes

If yes, state details. ________________________________________________________________

______________________________________________________________________________

14. List any insurers, prepaid dental plans, health care corporations or health maintenance organizations in which you control directly or indirectly or own legally or beneficially 10% or more of the outstanding stock (in voting power).

_____________________________________________________________________________

If any of the stock is pledged or hypothecated in any way, state details.

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15. Will you or members of your immediate family subscribe to own, beneficially or of record, shares of stock of the application entity or its affiliates? Yes

If any of the shares or stock are pledged or hypothecated in any way, state details.

_____________________________________________________________________________

16. Have you ever been adjudged bankrupt? Yes

If so, give details.

____________________________________________________________________________

17. Have you ever been convicted, had a sentence imposed or suspended, had a pronouncement of a sentence suspended, been pardoned for conviction of or pleaded guilty or no contest to any criminal information, indictment or complaint, other than minor traffic violations? Yes

If yes, state details.

____________________________________________________________________________

18. Have you ever been an officer, director, trustee, investment committee member, key employee, or controlling stockholder of any entity which, while you occupied any such position or capacity with respect to it, became insolvent or was placed under supervision or in receivership, rehabilitation, liquidation, conservatorship, or bankruptcy? Yes

If yes, state details.

____________________________________________________________________________

19. Has the certificate of authority or license to do business of any insurer, prepaid dental plan, health care corporation, or health maintenance organization of which you were an officer or director or key management person ever been suspended or revoked while you occupied such position? Yes

If yes, state details.

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Dated and signed this _______________day of _______________, __________ at _______________. I hereby certify under penalty of perjury that I am acting on my own behalf, and that the foregoing statements are true and correct to the best of my knowledge and belief.

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(Signature of Affiant)

State of _______________________________ County of ___________________

Personally appeared before me the above named __________________________ personally known to me, who being duly sworn, deposes and says that he executed the above instrument and that the statements and answers contained therein are true and correct to the best of his knowledge and belief.

Subscribed and sworn to before me this ______________day of _____________, _______.

(SEAL) _________________________________

(Notary Public)

My Commission Expires_______________________________