Domestic Fingerprints and Biographical Affidavit Requirements

Domestic Fingerprint and Biographical Affidavit Requirements

The chart below identifies the Fingerprint and Biographical Affidavit requirements for each Domestic Uniform State.

Group cover letters can be submitted with Biographical affidavits that are used for officer/director changes and for expansion and corporate amendment applications (The affiant and notary signatures on the biographical affidavit must be within 6 months of the date of submission) for companies listed on the group cover letter and are under the same group code. Only the NAIC cover letter can be submitted with a UCAA. Unless otherwise noted below all uniform states accept the group cover letter when a biographical affidavit is required.

Last Updated: 07/19/2024
Updates to the information will be noted with a “ * ” next to the state name and edits will be italicized and bolded.

State	Domiciliary Requirements for initial Licensure (Primary) or Other Application Types (Redomestication, Form A, Domestic Corporate Amendment)	Domestic Requirements (Updates Only, e.g. Annual, new officer, etc.)	State Contact Information
AL	Primary Application: NAIC Biographical Affidavit AND Independent Third-Party Verification Redomestication Application: Contact state Form A: Contact state Domestic Corporate Amendment: Contact state Disclaimer of Control: Allowed	After Licensure: NAIC Biographical Affidavits are required for changes in Officers, Directors or Key Managerial Personnel.	Biographical Affidavit and Third-Party Verification Reports: [email protected]
*AK	Primary Application: NAIC Biographical Affidavit and Independent Third-Party Verification Redomestication Application: Not required Form A: NAIC Biographical Affidavit and Independent Third-Party Verification Domestic Corporate Amendment: Not required Disclaimer of Control: Allowed	NAIC Biographical Affidavits are not required.	Biographical Affidavit: Primary/Redomestications: Jeffery Bethel P: (907) 269-7919 F: (907) 269-7898 [email protected] Corporate Amendments Applications: Kevin Richard P: (907) 269-7903 F: (907) 269-7910 [email protected] Third-Party Verification Reports: Secure email to: [email protected] [email protected] OR Mail to: Alaska Division of Insurance 550 W 7th Avenue, Suite 1560 Anchorage, AK 99501-3567
AZ	Primary Application: NAIC Biographical Affidavit AND Independent Third-Party Verification Redomestication Application: NAIC Biographical Affidavit AND Independent Third-Party Verification Form A: NAIC Biographical Affidavit AND Independent Third-Party Verification Domestic Corporate Amendment: Not Applicable Disclaimer of Control: Allowed	After Licensure: NAIC Biographical Affidavits are required for changes in Officers, Directors or Key Managerial Personnel.	Biographical Affidavit: Erica Bowsher [email protected] Third-Party Verification Reports: [email protected]
*AR	Primary Application: NAIC Biographical Affidavit and Independent Third-Party Verification. Redomestication Application: NAIC Biographical Affidavit and Independent Third-Party Verification - Ark. Code Ann. § 23-63-218 Form A: NAIC Biographical Affidavit and Independent Third-Party Verification - Ark. Code Ann. §§ 23-63-506 – 513 Domestic Corporate Amendment: NAIC Biographical Affidavit and Independent Third-Party Verification - Ark. Code Ann. § 23-69-107 Disclaimer of Control: Not Allowed	After Licensure: NAIC Biographical Affidavits are required for changes in Officers, Directors or Key Managerial Personnel.	Biographical Affidavit and Third-Party Verification Reports: Kimberly Johnson 501-371-2680 [email protected] [email protected]
*CA	Primary Application: Yes, Fingerprints and NAIC Biographical Affidavits. Please contact California's Department of Insurance directly at (415) 538-4035 to request the necessary fingerprint live scan Redomestication Application: Contact State Form A: Yes Domestic Corporate Amendment: Contact State	After Licensure: NAIC Biographical Affidavits and fingerprint are required for changes in Officers, Directors or Key Managerial Personnel. Disclaimer of Control: Allowed	Biographical Affidavit: [email protected] or 415-538-4035 Third-Party Verification Reports: Not Applicable - State Completes
CO	Primary Application: NAIC Biographical Affidavit, Fingerprints and Independent Third-Party Verification. Redomestication Application: NAIC Biographical Affidavit, Fingerprints and Independent Third-Party Verification. Form A: NAIC Biographical Affidavit, Fingerprints and Independent Third-Party Verification. Domestic Corporate Amendment: n/a Disclaimer of Control: Allowed	After Licensure: NAIC Biographical Affidavits are required for changes in Officers, Directors or Key Managerial Personnel.	Biographical Affidavit and Third-Party Verification Reports: Cindy Hathaway [email protected]
*CT	Primary Application: NAIC Biographical Affidavits and Independent Third-Party Verification. Redomestication Application: NAIC Biographical Affidavits and Independent Third-Party Verification. Form A: NAIC Biographical Affidavits and Independent Third-Party Verification. Domestic Corporate Amendment: Yes Disclaimer of Control: Not Allowed	NAIC Biographical Affidavits are required when there is a change in or new officers, directors, and key managerial as soon as possible.	Biographical Affidavit: [email protected] 860-297-3800 Third-Party Verification Reports: Contact state
*DE	Primary Application: NAIC Biographical Affidavit and Third-Party Verification. Redomestication Application: NAIC Biographical Affidavit and Third-Party Verification. Form A: NAIC Biographical Affidavit and Third-Party Verification. Domestic Corporate Amendment: if applicable Disclaimer of Control: Not Allowed	After Licensure: NAIC Biographical Affidavits are required for changes in Officers, Directors or Key Managerial Personnel.	Biographical Affidavit: [email protected] Third-Party Verification Reports: [email protected]
DC	Primary Application: NAIC Biographical Affidavits and Independent Third-Party Verification. Redomestication Application: Contact Jurisdiction Form A: Contact Jurisdiction Domestic Corporate Amendment: Contact Jurisdiction Disclaimer of Control: Allowed	After Licensure: NAIC Biographical Affidavits are required for changes in Officers, Directors or Key Managerial Personnel.	Biographical Affidavit and Third-Party Verification Reports: Nathaniel Kevin Brown Director - Financial Examinations, Insurance Bureau Department of Insurance, Securities and Banking 1050 First Street, NE, Suite 801 Washington, DC 20002 Telephone (202)442-7785 [email protected]
*FL	Primary Application: Licensure: NAIC Biographical Affidavit, Independent Third-Party Verification and Fingerprint Cards (Fingerprint LiveScan available for Florida Residents Only). Refer to State Specific Requirements for Fingerprint Procedures. Please contact the Office of Insurance Regulation at (850) 413-2575 to request the necessary fingerprint cards or [email protected]. Redomestication Application: Same as Primary Form A: Same as Primary Domestic Corporate Amendment: Not required Disclaimer of Control: Allowed at the Office's discretion	After Licensure: Any change in officer/director requires NAIC Biographical Affidavit, Independent Third-Party Verification and Fingerprint Cards (Fingerprint LiveScan available for Florida Residents Only). Refer to State Specific Requirements for Fingerprint Procedures. Please contact the Office of Insurance Regulation at (850) 413-2575 to request the necessary fingerprint cards or [email protected].	Biographical Affidavit: Life & Health Companies: Joe Erhart, Applications Coordinator Phone 850-413-5066 Email [email protected]) Property & Casualty Companies: Wesley White Applications Coordinator Phone 850-413-5225 Email [email protected] Third-Party Verification Reports: [email protected]
GA	Primary Application: NAIC Biographical Affidavit and Independent Third-Party Verification Redomestication Application: NAIC Biographical Affidavit and Independent Third-Party Verification Form A: NAIC Biographical Affidavit and Independent Third-Party Verification Domestic Corporate Amendment: NAIC Biographical Affidavit Disclaimer of Control: Not Allowed	Contact state for requirements.	Biographical Affidavit: [email protected] Third-Party Verification Reports: [email protected] and [email protected]
HI	Contact state for requirements.	Contact state for requirements.	Contact state.
ID	Primary Application: NAIC Biographical Affidavit and Independent Third-Party Verification Redomestication Application: NAIC Biographical Affidavit and Independent Third-Party Verification Form A: Contact State Domestic Corporate Amendment: Contact State Disclaimer of Control: Not Allowed	After Licensure: NAIC Biographical Affidavit and Independent Third-Party Verification report is required for changes in Officers, Directors or Key Managerial Personnel.	Biographical Affidavit and Third-Party Verification Reports: [email protected]
*IL	Primary Application: Current Version of the NAIC Biographical Affidavits with original signatures and the bios shall be notarized required for all domestic companies’ Officers and Directors. Independent Third-Party Verification Reports are required for all Officers and Directors. Redomestication Application: Current Version of the NAIC Biographical Affidavits with original signatures and the bios shall be notarized required for all domestic companies’ Officers and Directors. Independent Third-Party Verification Reports are required for all Officers and Directors. Form A: Contact state Domestic Corporate Amendment: Contact state Disclaimer of Control: Not Allowed	After Licensure: Current Version of the NAIC Biographical Affidavits with original signatures and being notarized are required for changes in Officers or Directors; Independent Third-Party Verification *Reports* are required for new Officers or Directors. Notification of a change in officers or directors is required within 30 days.	Biographical Affidavit: Property/Casualty Companies: Tammy Jones [email protected] Life, Accident & Health Companies: Pearl Stanulis [email protected] Third-Party Verification Reports: Mail to: Illinois Department of Insurance Attn: Corporate Regulation Section 320 West Washington Street– 4^th Floor Springfield, IL 62767
IN	Indiana Biographical Affidavits with electronic signature which complies with the electronic transaction act (IETA)(IC 26-2-8-108) and Independent Third-Party Verification required for all domestic companies Note: Electronic signatures from commercially available software, such as Docusign or Esign, are acceptable. “Check the Box” signatures or “Rubber Stamp” signatures Do Not Comply. Disclaimer of Control: Allowed	Electronically signed Indiana Biographical Affidavits are required for changes in Officers, Directors or Key Managerial Personnel. Disclaimer of Control: Allowed Note: Electronic signatures from commercially available software, such as Docusign or Esign, are acceptable. “Check the Box” signatures or “Rubber Stamp” signatures Do Not Comply.	Application Submissions Primary, Redomestication Connie Wright (317) 232-1994 [email protected] Form A, Corporate Amendment Annette Gunter (317) 232-2428 [email protected] Updates Heather Brewer (317) 232-2390 [email protected]
IA	Primary Application: NAIC Biographical Affidavit and Independent Third-Party Verification Redomestication Application: Contact Iowa Insurance Division regarding Biographical Affidavits Form A: NAIC Biographical Affidavit and Independent Third-Party Verification Domestic Corporate Amendment: Contact state Disclaimer of Control: Allowed	After Licensure: Biographical Affidavits are required for changes in Officers, Directors or Key Managerial Personnel.	Biographical Affidavit and Third-Party Verification Reports: Dana Sanders [email protected] or Iowa Insurance Division Attn: Dana Sanders 1963 Bell Avenue Des Moines, Iowa 50315
KS	Primary Application: NAIC Biographical Affidavit and Independent Third-Party Verification. Redomestication Application: NAIC Biographical Affidavit and Independent Third-Party Verification. Form A: NAIC Biographical Affidavit and Independent Third-Party Verification. Domestic Corporate Amendment: None Disclaimer of Control: Contact state	After Licensure: NAIC Biographical Affidavit for changes in Officers and Directors as listed on page one of the annual statement within 30 days after the changes or actions become effective or are otherwise finalized.	Biographical Affidavit and Third-Party Verification Reports: Tish Becker Kansas Insurance Department [email protected] 785-296-7816 Third-party background reports should be sent electronically (via e-mail) to the following state contact: Tish Becker [email protected]
KY	Contact state for requirements.	Contact state for requirements.	Contact state.
LA	Primary Application: Complete Biographical Affidavits (Form 11) on most current form for all Officers and Directors. Independent Third-Party Verifications required for all Officers and Directors. Domestic applicants must submit fingerprints in compliance with the state requirements. More information on fingerprint requirements at http://www.ldi.la.gov/industry/company-licensing/application-forms/ucaa…. Redomestication Application: Same as Primary Application Form A: Same as Primary Application Domestic Corporate Amendment: Contact state Disclaimer of Control: Allowed	After Licensure: Complete Biographical Affidavits (Form 11) on most current form for all new Officers and Directors. Independent Third-Party verifications required for all new Officers and Directors. All new Officers and Directors must submit fingerprints in compliance with state requirements. More information on fingerprint requirements at http://www.ldi.la.gov/industry/company-licensing/application-forms/ucaa….	Biographical Affidavit and Third-Party Verification Reports: Tangela Byrd Insurance Manager Louisiana Department of Insurance 1702 North 3^rd Street (70802) P.O. Box 94214 Baton Rouge, LA 70804-9214 [email protected]
ME	Contact state for requirements.	Contact state for requirements.	Contact state.
MD	Primary Application: NAIC Biographical Affidavits and Independent Third-Party Verification. Redomestication Application: NAIC Biographical Affidavits and Independent Third-Party Verification. Form A: NAIC Biographical Affidavits and Independent Third-Party Verification. Domestic Corporate Amendment: NAIC Biographical Affidavits and Independent Third-Party Verification. Disclaimer of Control: Not Allowed	After Licensure: NAIC Biographical Affidavits with original signatures are required for changes in Officers, Directors. Independent Third-Party Verifications are required for new Officers or Directors. Notification of a change in Officers or Directors is required within 3-days.	Biographical Affidavit and Third-Party Verification Reports: Erin Nickels Mailing address: Maryland Insurance Administration 200 St. Paul Place, Suite 2700 Baltimore, Maryland 21202 Email address: [email protected]
MA	Contact state for requirements.	Contact state for requirements.	Contact state.
MI	Primary Application: NAIC Biographical Affidavit dated within 6 months of filing application and Independent Third-Party Verification Report required Redomestication Application: NAIC Biographical Affidavit dated within 6 months of filing application and Independent Third-Party Verification Report required Form A: NAIC Biographical Affidavit dated within 6 months of filing and Independent Third-Party Verification Report required for the new UCP (those with a greater than 10% ownership) and any proposed officer or director of the domestic insurer. Domestic Corporate Amendment: not required Disclaimer of Control: not required	After Licensure: NAIC Biographical Affidavit dated within 6 months of change and Independent Third-Party Verification are required for changes in Officers, Directors or Key Managerial Personnel.	Biographical Affidavit and Third-Party Verification Reports: Third party verifications should be sent directly to DIFS by the third-party verifier. Send to : Linda Martin, Application Coordinator, 517-284-8756 or [email protected] If reports cannot be sent electronically, hard copies should be sent to: Linda Martin, Application Coordinator Michigan Department of Insurance and Financial Services Office of Insurance Financial and Market Regulation P. O. Box 30220 Lansing, MI 48909 OR 530 W. Allegan St., 7th Fl. Lansing, MI 48933
MN	Primary Application: NAIC Biographical Affidavit and Independent Third-Party Verifications are required for Primary Applications. Signatures must be original, and dated within 6 months of application. Redomestication Application: NAIC Biographical Affidavit and Independent Third-Party Verifications are required. Signatures must be original, and dated within 6 months of application. Form A: NAIC Biographical Affidavit and Independent Third-Party Verifications are required. Signatures must be original, and dated within 6 months of application. Domestic Corporate Amendment: Articles/Bylaws - not needed. Disclaimer of Control: Not Allowed	After Licensure: Any new individual on the Jurat page must submit an NAIC Biographical Affidavit dated within 6 months, original or digital signatures are accepted.	NAIC Biographical Affidavit: Domestic companies should submit to [email protected] within 60 days of the change.
MS	Primary Application: NAIC Biographical Affidavit and Independent Third-Party Verifications are required for Primary Applications. Signatures must be original. Redomestication Application: NAIC Biographical Affidavit Form A: NAIC Biographical Affidavit and Independent Third-Party Verifications are required for Primary Applications. Signatures must be original. Domestic Corporate Amendment: NAIC Biographical Affidavit Disclaimer of Control: Not Allowed	Notification and a NAIC Biographical Affidavit are required for all new officers and directors	Biographical Affidavit: Chad Bridges Email: [email protected] Phone #: 601-359-2136 Third-Party Verification Reports: Electronic Method Preferred: Email: [email protected] or [email protected]
MO	Primary Application: NAIC Biographical Affidavit and Independent Third-Party Verification. Redomestication Application: NAIC Biographical Affidavit and Independent Third-Party Verification. Form A: NAIC Biographical Affidavit and Independent Third-Party Verification. Domestic Corporate Amendment: Depends on the corporate amendment type Disclaimer of Control: Allowed, but must be submitted as a separate filing for consideration		Biographical Affidavit: [email protected] (573)526-4877 Third-Party Verification Reports: Third party verification reports should be sent in a secure fashion. We prefer to establish box accounts where the vendors can upload the reports. Each box account is specific to the vendor. Contact our Division at [email protected] to set up an account.
MT	Primary Application: NAIC Biographical Affidavit Redomestication Application: Contact state Form A: Contact state Domestic Corporate Amendment: Contact state Disclaimer of Control: Allowed	After Licensure: NAIC Biographical Affidavits are required for changes in Officers, Directors or Key Managerial Personnel.	Biographical Affidavit and Third-Party Verification Reports: Tavin Mogus [email protected] 406-444-3496
NE	Primary Application: UCAA biographical affidavit and 3^rd party verifications, no fingerprints Redomestication Application: NAIC biographical affidavit and 3^rd party verifications, no fingerprints Form A: NAIC biographical affidavit and 3^rd party verifications, no fingerprints Domestic Corporate Amendment: It will vary depending on amendment, check with the DOI Disclaimer of Control: Contact state	All officer, director, or key personnel changes require biographical affidavit	Primary Application, Redomestication, Corporate Amendments: [email protected] Officer Updates: [email protected]
NV	Contact state for requirements.	Contact state for requirements.	Contact state.
NH	Primary Application: NAIC Biographical Affidavit Redomestication Application: Contact state Form A: Contact state Domestic Corporate Amendment: Contact state Disclaimer of Control: Allowed	After Licensure: NAIC Biographical Affidavits are required for changes in Officers, Directors or Key Managerial Personnel.	Biographical Affidavits; Third-Party Verification Reports only if requested: [email protected]
NJ	Primary Application: Primary P&C - NAIC Biographical Affidavit and criminal history record check by the New Jersey State Police. Link: https://www.njportal.com/NJSP/CriminalRecords/Default.aspx. Once at the website enter Originating Agency Identifier (ORI) #: NJDINS11X. Primary L&H: NAIC Biographical Affidavit and Independent Third-Party Verification. Contact the Department for state specific information (Solvency Regulation 609-292-7272). Redomestication Application: NAIC Biographical Affidavit and criminal history record check by the New Jersey State Police. See link above. Form A: NAIC Biographical Affidavit, Independent Third Party Verification (with NAIC approved vendor), and criminal history record check by the New Jersey State Police. Submit inquiries pertaining to the filing of a Form A to: [email protected] Domestic Corporate Amendment: Same as Primary App. Required for new officers/directors or individuals holding a controlling interest in insurer. Disclaimer of Control: Separate filing required	After Licensure P&C: NAIC Biographical Affidavit and criminal history record check by the New Jersey State Police. After Licensure L&H: NAIC Biographical Affidavit, and Independent Third-Party Verification.	Biographical Affidavit and Third-Party Verification Reports: [email protected]
NM	Primary Application: NAIC Biographical Affidavit and Independent Third-Party Verification. Redomestication Application: NAIC Biographical Affidavit and Independent Third-Party Verification Form A: NAIC Biographical Affidavit and Independent Third-Party Verification. Domestic Corporate Amendment: Contact state Disclaimer of Control: Not Allowed	After Licensure: NAIC Biographical Affidavits submitted in hard copy for changes in Officers/Directors.	Biographical Affidavit and Third-Party Verification Reports: Ursula Almada [email protected] Victoria Baca [email protected]
*NY	*Primary Application: NAIC Biographical Affidavit AND Independent Third-Party Verification* *Redomestication Application: NAIC Biographical Affidavit AND Independent Third-Party Verification* Form A: NAIC Biographical Affidavit AND Independent Third-Party Verification Domestic Corporate Amendment: not required Disclaimer of Control: Contact state	*After Licensure: NAIC Biographical Affidavit and Independent Third-Party Verification are required for changes in Officers, Directors or Key Managerial Personnel.*	*Biographical Affidavit and Third-Party Verification Reports:*  Third party verification reports should be sent directly to NY DFS by the third-party vendor using the DFS Portal (an account is not required). A copy of the biographical affidavit is required to be included with the report. State Email Contacts: Property and Casualty Health Life
NC	Contact state for requirements.	Contact state for requirements.	Contact sate.
ND	Primary Application: NAIC Biographical Affidavit and Independent Third-Party Verification Redomestication Application: NAIC Biographical Affidavit and Independent Third-Party Verification Form A: NAIC Biographical Affidavit and Independent Third-Party Verification Domestic Corporate Amendment: N/A Disclaimer of Control: Not Allowed	After Licensure: NAIC Biographical Affidavits are required for changes in Officers, Directors or Key Managerial Personnel.	Biographical Affidavit: Matt Fischer [email protected] or Nichole Feldman [email protected] Third-Party Verification Reports: [email protected]
OH	Primary Application: NAIC Biographical Affidavit and Independent Third-Party Verification Redomestication Application: Contact state Form A: Contact state Domestic Corporate Amendment: Contact state Disclaimer of Control: Allowed	After Licensure: NAIC Biographical Affidavits are required for changes in Officers, Directors or Key Managerial Personnel.	Biographical Affidavit and Third-Party Verification Reports: Cam Piatt [email protected] 614 728-1074
OK	Contact state for requirements.	Contact state for requirements.	Contact state.
OR	Contact state for requirements.	Contact state for requirements.	Contact state.
PA	Primary Application: NAIC Biographical Affidavit Redomestication Application: Contact state Form A: Contact state Domestic Corporate Amendment: Contact state Disclaimer of Control: Allowed	After Licensure: NAIC Biographical Affidavits are required for changes in Officers, Directors or Key Managerial Personnel.	Biographical Affidavit: Diana L. Sherman Acting Deputy Commissioner 1345 Strawberry Square Harrisburg, PA 17120 Phone: 717.503.5462 Email: [email protected] Third-Party Verification Reports: Not Required
*PR	Primary Application: NAIC Biographical Affidavit and Independent Third-Party Verification Redomestication Application: Contact state Form A: Contact State Domestic Corporate Amendment: Contact state Disclaimer of Control: Allowed	After Licensure: NAIC Biographical Affidavits are required for changes in Officers, Directors or Key Managerial Personnel.	Biographical Affidavit and Third-Party Verification Reports: Glorimar Santiago [email protected] Maria Morcelo [email protected]
RI	Contact State Disclaimer of Control: Allowed	NAIC Biographical Affidavit is required for new Officers and Directors within a reasonable time frame.	Biographical Affidavit and Third-Party Verification Reports: Ted Hurley [email protected]
SC	Primary Application: NAIC Biographical Affidavit and Independent Third-Party Verification are required. Redomestication Application: NAIC Biographical Affidavit and Independent Third-Party Verification are required. Form A: NAIC Biographical Affidavit and Independent Third-Party Verification are required. Domestic Corporate Amendment: NAIC Biographical Affidavit and Independent Third-Party Verification are required. Disclaimer of Control: Allowed	After Licensure: NAIC Biographical Affidavits are required for changes in Officers, Directors or Key Managerial Personnel. Disclaimer of Control: Allowed	Biographical Affidavit and Third-Party Verification Reports: Deonna G. Rogers [email protected]
SD	Primary Application: NAIC Biographical Affidavit Redomestication Application: Contact state Form A: Contact state Domestic Corporate Amendment: Contact state Disclaimer of Control: Contact state	After Licensure: NAIC Biographical Affidavits are required for changes in Officers, Directors, or Key Managerial Personnel	Biographical Affidavit: Domestics should contact their individual financial analyst or [email protected] Third Party Verification Reports: Johanna Nickelson Assistant Director Company Solvency and Licensing SD Division of Insurance 124 S. Euclid Ave., 2^nd Floor Pierre, SD 57501
TN	Primary Application: Biographical affidavits and third-party background checks of board members and officers. Redomestication Application: Biographical affidavits and third-party background checks of board members and officers. Form A: Biographical affidavits and third-party background checks of board members and officers. Domestic Corporate Amendment: Biographical affidavits and third-party background checks of new board members and officers. Disclaimer of Control: Contact state	Biographical affidavits and third-party background checks of new board members and officers.	Biographical Affidavit and Third-Party Verification Reports: Hui Wattanaskolpant [email protected]
TX	Primary Application: NAIC Biographical Affidavit, Identogo Fingerprint receipts, and Independent Third-Party Verifications for all directors and only the following officers: CEO, President, Executive Director, Secretary, Treasurer, CFO/Controller, COO and Medical Director (if applicable) and any individuals that own 10% or more, beneficial ownership in the Applicant Company and the Applicant Company’s ultimate controlling person. We DO NOT require biographical affidavits, Identogo Fingerprint receipts, and Third-Party verifications for Vice Presidents or Assistant-officers. Redomestication Application: Same requirements as the Primary application Form A: Fingerprint Requirements and Instructions found at https://www.tdi.texas.gov/agent/fingerprint-instructions.html Domestic Corporate Amendment: Only if officer/director changes have been made Disclaimer of Control: Not Allowed	After Licensure: NAIC Biographical Affidavits and Fingerprint receipts are required for changes to Domestic insurers directors and only the following officers: CEO, President, Executive Director, Secretary, Treasurer, CFO/Controller, COO and Medical Director (if applicable). We DO NOT require biographical affidavits for Vice Presidents or Assistant-officers.	Biographical Affidavit: Laura Weld [email protected] Third-Party Verification Reports: [email protected]
*UT	Primary Application: NAIC Biographical Affidavit and Independent Third-Party Verification. Redomestication Application: NAIC Biographical Affidavit and Independent Third-Party Verification. Form A: Contact state Domestic Corporate Amendment: Contact state Disclaimer of Control: Allowed	After Licensure: NAIC Biographical Affidavit and Independent Third-Party Verification are required for changes in Directors, Officers and Key Managerial Personnel of domestic company or ultimate controlling person.	Biographical Affidavit and Third-Party Verification Reports: Jay Sueoka [email protected] or [email protected]
VT	Primary Application: NAIC Biographical Affidavit & Third-Party Verification is required. Redomestication Application: NAIC Biographical Affidavit & Third-Party Verification is required. Form A: NAIC Biographical Affidavit & Third-Party Verification is required. Domestic Corporate Amendment: NAIC Biographical Affidavit maybe required Disclaimer of Control: Not Allowed	After Licensure Updates: NAIC Biographical Affidavit; Independent Third-Party Verification may be required.	Biographical Affidavit: (802)-828-2470 or [email protected] Third-Party Verification Reports: Contact state if requested
VA	Primary Application: NAIC Biographical Affidavit and Independent Third-Party Verification. Redomestication Application: Contact state Form A: Contact state Domestic Corporate Amendment: Contact state Disclaimer of Control: Allowed	After Licensure: NAIC Biographical Affidavits are required for changes in Officers, Directors or Key Managerial Personnel.	Biographical Affidavit and Third-Party Verification Reports: Kevin McClain Financial Analyst Direct Line: (804) 371-9432 [email protected]
WA	Primary Application: NAIC Biographical Affidavit and Independent Third-Party Verification. Redomestication Application: NAIC Biographical Affidavit and Independent Third-Party Verification as required by UCAA requirements Form A: NAIC Biographical Affidavit and Independent Third-Party Verification of acquiring persons Domestic Corporate Amendment: NAIC Biographical Affidavit and Independent Third-Party Verification. Disclaimer of Control: Allowed	After Licensure: NAIC Biographical Affidavits are required for changes in Officers, Directors or Key Managerial Personnel. Domestic insurers must file a biographical affidavit every thirty-six months after the last biographical affidavit filed.	Biographical Affidavit: Jason Carr [email protected] Third-Party Verification Reports: [email protected]
WV	Primary Application: NAIC Biographical Affidavit is required. Redomestication Application: NAIC Biographical Affidavit is required if there are changes. Form A: NAIC Biographical Affidavit is required if there are changes. Domestic Corporate Amendment: NAIC Biographical Affidavit is required if there are changes. Disclaimer of Control: Not Allowed	After Licensure: NAIC Biographical Affidavit is required for new officers and/or directors AND amendments to officers and/or directors.	WV Offices of the Insurance Commissioner Financial Conditions Division (304) 558-2100 [email protected] Do not email Bio's to the above email. They can be viewed in UCAA or sent to: WV Offices of the Insurance Commissioner Financial Conditions Division PO Box 50540 Charleston, WV 25305-0540 Third-Party Verification Reports:* Third-Party Verification Reports are required.
WI	Primary Application: NAIC Biographical Affidavit required (but not fingerprints or Independent Third-Party Verifications) Redomestication Application: NAIC Biographical Affidavit required (but not fingerprints or Independent Third-Party Verifications) Form A: NAIC Biographical Affidavit required (but not fingerprints or Independent Third-Party Verifications) Domestic Corporate Amendment: Contact state Disclaimer of Control: Allowed	After Licensure: NAIC Biographical Affidavit required for any changes in Directors, Officers or Key Managers (but not fingerprint or Independent Third-Party Verifications).	Biographical Affidavit: Suzanne Vinmans [email protected] or Mark McNabb [email protected] or Christopher Martin [email protected] Third-Party Verification Reports: Contact the state if requested
WY	Primary Application: NAIC Biographical Affidavit and Independent Third-Party Verification. Redomestication Application: NAIC Biographical Affidavit and Independent Third-Party Verification. Form A: NAIC Biographical Affidavit and Independent Third-Party Verification. Domestic Corporate Amendment: NAIC Biographical Affidavit and Independent Third-Party Verification. Disclaimer of Control: Not Allowed	After Licensure: NAIC Biographical Affidavits are required for changes in Officers, Directors or Key Managerial Personnel.	Biographical Affidavit and Third-Party Verification Reports: Doug Melvin [email protected]

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