TAILIEUCHUNG - Uniform Application for Business Entity Insurance License/Registration

The automotive industry is becoming evermore global, and our international presence has been a key factor in the recent growth of the Agency. The South American markets have developed rapidly in recent years, and have become a key sector for many of our customers. Therefore the Agency is planning to establish a local presence in this region. The quality of our service has underpinned our delivery, and we need to continually invest in improving our standards. Our Ministerial outcomes will focus on improving systems, quality of service, and efficiency of delivery. We. | NAIC Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application please reference the National Insurance Producer Registry web site at . Uniform Application for Business Entity Insurance License Registration InsuranaCommissionen Please Print or Type Check appropriate box for license requested. Resident License Non-Resident License o Identify Home State o Identify Home State License Demographic Information 3 Business Entity Name 3 Incorporation Formation Date FEIN month day year - 0 If assigned National Producer Number NP If applicable FINRA Firm Central Registration Depository CRD List any other assumed fictitious alias or trade names under which you are doing business or intend to do business. State of Domicile Country of Domicile 93 Is the business entity affiliated with a financial institution bank Yes No 0 Business Address 0City 2 State 3 Zip Code 4 Foreign Country f5 Phone Number include 16 Fax Number extension - _ Business Web Site Address Business E-Mail Address 19 Mailing Address . Box City State Zip Code 24 Foreign Country Designated Responsible Licensed Producer 5 Identify at least one Designated Responsible Licensed Producer responsible for the business entity s compliance with the insurance laws rules and regulations of this state. See Matrix of State Requirements at for jurisdictions that require the designaĩed responsible licensed producer to be an officer director or partner of the business entity. Name SSN - - NPN Name SSN - - NPN Name SSN - - NPN Name SSN - - NPN Owners Partners Officers and Directors Ễ6 Identify all owners with 10 interest or voting interest partners officers and directors of the business entity or members or managers of a limited liability company Name Title SSN FEIN - - Owner Yes No of ownership interest Name Title SSN FEIN - - Owner Yes No of ownership interest Name Title SSN FEIN - - Owner Yes No of ownership interest Name Title .

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