1. Name of Applicant:
Federal I.D. No.:
2. Principal Business Address:
City:
County:
State:		Zip Code:
Telephone:

If principal business address is changed, the Department of Insurance and Securities Regulation must by notified in writing.

Does your partnership or any officer(s), or designated director(s) and employee(s), intend to act as reinsurance intermediaries from an address in the District of Columbia? If yes, where?	Yes    No

3. Date of organization of partnership:
Under the laws of what state is applicant organized?

(Attach copy of current Certificate of Authority for state of incorporation and certification of Authority for District of Columbia.)

4. List all partners, members and designated employees and give information requested below. (List partners first, followed by designated employees.)

Name:		Title:
Partner:	Yes    No
Date of Birth:		Sex:	Male    Female
Will act as Intermediary:	Yes    No
Resident Address:
Social Security No.:

Name:		Title:
Partner:	Yes    No
Date of Birth:		Sex:	Male    Female
Will act as Intermediary:	Yes    No
Resident Address:
Social Security No.:

Name:		Title:
Partner:	Yes    No
Date of Birth:		Sex:	Male    Female
Will act as Intermediary:	Yes    No
Resident Address:
Social Security No.:

Name:		Title:
Partner:	Yes    No
Date of Birth:		Sex:	Male    Female
Will act as Intermediary:	Yes    No
Resident Address:
Social Security No.:

5. List any person, firm, association or corporation who or which, directly or indirectly, has the power to direct or cause to be directed, the management, control or activities of the applicant. If none, check here.
Name:
Address:
Name:
Address:
Name:
Address:

Explain how each person, firm, association or corporation listed above directs the management, control or activities of the applicant.

6. Has applicant, or any of its members, designated employees, or controlling person listed in Questions 4 and 5 above, or any partnership or corporation with which they are, or were formerly associated, during their connection therewith, ever:
a) Been discharged by or had a contract of agency terminated by an insurer or employer?	Yes    No
b) Been charged in any capacity whatsoever with irregularities in money or any other transactions?	Yes    No
c) Compromised his/her, or its, liabilities with creditors; been insolvent or adjudged a bankrupt?	Yes    No
d) Been refused a license or had an existing one suspended or revoked by the Department of Insurance and Securities Regulation, or by any state or governmental agency or authority?	Yes    No
e) Been fined by any state or government agency or authority?	Yes    No
f) Excluding minor traffic violations, been convicted of any crime which has not been annulled by a court?	Yes    No
If answers to a. through f. are "YES", give full details.