northwest dentists insurance company acquisition by the ... · from parkside dental 1.951.688.4744...

From Parkside Dental 1.951.688.4744 Tue Jun 28 09:50:39 2016 PDT of16

Applicant Company Name: The Dentists Insurance Company NAlC No. 40975 FElN: 94-2698799

BIOGRAPHICAL AFFIDAVIT

To the extent permitted by law, this affidavit will be kept confitlentiul by the state insurance regulatory authority.

(Print 01· Ty1Jo)

Ful1 nan,e, address and tcll!phonc: number of the present or proposed enti1y under \Vhich this biographical siaternent is being required (Do Not Use Group Na1nes).

The UentistsJnsurance Compan)' 120 I K Street. J7"' PloouMcramcnto, CA 95814

rnoo)733-0634

[u c,;onoection with the above·namcd entity, I hcrc¥:iU1 1nake representations and supply in!Ortnation about myself as hercinaft.cr set forth. (Attach addenllum or scpaL'ate sheet if space hereon is insufficient to answer any question ti11ly,) IF ANSWER IS "NO" OR "NONE," SO STATE,

1. Alfonl's Pull Name (Initials Not Acceptable): Fir>t,S,r .. lei Middlc:_,JJ;c,\q;) Last: //tJJ/lcf""::!_ __

2. u. Arc you a ell izetl of the U nitcd States?

Yes l..1< ] No [_ I b. Are you a citizen of ~i.ny other country?

Yes [ -:=J No [ X]

If yes, Yl'hal country? __ ·~··--·---

3. Afl1ant's occupii.lion or pt'ofession: De1,--f 1:S-/' 4. Afflnnt's business actctress:--':J.;),J..'-/ ~1vrrw,, lLiki,.,t s~: 1e 100 Rwers,/"' C<i.~:,-

susiness telephone: {j51) &.?8_~s'-j.g Business E1ttuil: __ d r M ;J.,/fc -k-"'6. J m Jro -/rl ..-..<,;. 01>1_

1. Education and tniinlng:

CollegeltJnivmity CitylSt;!\ll Dates Atten<lc!liMM/YY) _J.)egl'ee Obt~1ln~Q

C~~-·/_,,f.~,1_n~1"'""'. S_-f_4~~-e_ll_11~··v-'t1"'"l'""'Jfy,___l_"'_~-'f::'f-&-"~'·~f.. __ i_"1_. _!~1~8--"'-1_--'l-'"l,,_i_,7~ __ fS_ • .A__Pr1cU'!Jy

Ot[1~r Tn1it1ing: Na.ll~ Citv/Sla!~ Dates Attended Ctv1M/YY) [)cg~~e/Certification Obt.fil.will

fa~qld· AM:jgJ .1!!,j.;, I l;-:~lli·'y,. LA .Jj~/_.:; z_ . __ G.P, V?. C<>J°l,[."c.,/.~ >Jote: If affiant <Jtttr)ded a foreign !;chool, please prov id~ full address and telephone number of the cu liege/university. Ir

applicable, providt.~ the foreign student ldenrification Nu1nb~r in the space provided in the l3iogrnphii.:u.\ Affidavit Supplcn1enta\ Infonnation.

©2016 >Jational A~sol'.iation of lnsurailcc Comn1issiont:l's Rcvist:li 8/ 18/ l 4

H)RM II

From Parkside Dental 1.951.688.4744 Tue Jun 28 09:50:39 2016 PIJT of 16

6. List of rne111b~rships in profe:;,sional societies and nssocitllions:

Jiamc o( Soci etyl As.sncialion Contact ·Na1nc

Addrc~.ol SosietvJ Association

T elephont: Nun\ her gJSccicty/As.wdl!!ilm

7.

;,7 II 5..s-1 Ct,,,;~"- ,4.,,,. Cti,~ ·J·, ! L.. (j1'l.)'-WO-:Xco

''<>' k ~.,,.,.-11 s""I'-~• .. ~·+ .. ~L.="'--e· -~'e~)~QJJ -76'K"

31'13 'S•t~f< Ave ¥/O'f()/1",,a,,;l,,C~. &=>!)7iJ-97oo

Present or proposed position with the Applicant Company: ,. 11.e,.. &,r Doer.A o.f._J_[ ... f,Tl!fl: r

' . l( i · Co,e'i;c {),~-/,I .5,,,c1e·1.x__

----·----·-------· 8. List complete employment record for the past twenty (20) years, \lfh1..-thcr compcns,1ted or otherwise (up to and

including present jobs-1 positions, partnerships, owner of an entity, adn1inistrator, manager, operaLor:,- directorates or officerships). Please list the most recent first. Atlach additional pages ifd1e space provided is insufficient. It is only necessary to provide Cclcphone numbers and supervisory infom1atJOn_ for the past ten ( l 0) years.

BcginniQ-g/Endin&.-Dates (MM/YY):-,kn( :icq;., Pr'J,,+ Employer'sName:_~r~'J ':'.li. /14(//1.z-I~,, O.f.J.s. Inc.

Address; !i§.:.3't~i~-'-'.' ik j{, k ~i-City: -~' ~'<' rr • ,/, Stute/Province: __ L . .'O_,_._, __ _

Country: Jd..5 .£L.- Postal Code: .'.J J.5'05 Phonct'.cil.1L~..J'f'f?omces!Position< Held: C. &CJ __ _

Type ufBusiness: ~"'/ c:J t{~ ( Supcrvisu1iContact:~JK. L!:'J;JJ/e;f.,." BcginningtEnding

1 / - I '· /

Dates (MMIYY): J1!'M 3 _ • -~(~ Employer's Name: b(r-f) /"1 ft!' j)/er -/""".. /',,..

Address: 3~8' fJ'i"fO ....f2.'ff {',~ trl City; _..JE JtdfJ 1/tt ... ~- State/Province:_<....... __ ..... _, __ , __ _

Country: ws:.fl.__ Postal Code: q 2 S"o 3 _ Phone: Z1s ~.?~.'!'.!... Offices/Po,ilions Held: Ov,,,., I Type ofBusincss: . Q,,-. ·1, f 0 tf..~_t? __ Supervisor/Cllntact:_.~">1 $~ __ .!!/2//le '1'a,.

Beginning/Ending Dales. (MMIYY): ___ · ___ Employer's Name:

----·~-···----·-- .. ,, _____ _ Address: ·--··--City: .. --··· ·-·---- State/Province: -----·

COUlltry: ----·-,-· Postal Code: ___ .. _Plione: __ _ .. _ OtliceslPositions Held:

Type of_Business: SupervisorrConlact: ______ _

l3egi11ning/EndU1g

Dates (MM/YY): ---·- - ··---Employer's Name:_ .. - .. ---·----- ...... __ .. ___ _ Addreos: __ _ _ __ City: Stale/Province:

Country:----·_ Postal Code: ~--··_Phone: . ______ Offices/Positions 11.eld: -·--· ___ _

Type ofl3usint~ss: _ ------.. --.-- Supervisor/Contact:_ ---··-.··-~--------

©2(116 Nationnl Association of ln:;urance Cornmis:>ioncrs Revised 8/18/14

FORM II

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From Parkside Dental 1.951.688.4744 Tue Jun 28 09:50:39 2016 PDT of 16

Applicant Company Name : 1'he Dentists Insurance Company NAIC No. 40975

9. FEJN: 94-2698799

a. Have you ever been in a position which required a fidelity bond?

Yes C:.:-:J No lXJ lf an>' clairns: \Vere rnade on the bonll, gi\•e details:--··-·

--· - -------... --- . ·--·-----·-··-· ----b. Have you ever been denied an individual or position schedule fhlclily bond, or had a bond cancclt!<l or

revoked?

Yes C_J No l.XJ Ifye-s, give details: _____ . ____ _

--- ---··-------- -----.----------I 0. List any professional, occupalional and vocational licenses (including licenses to sell securities) issued by any public

or govcrnme1Hnl licensing ngency or regula~ory nuthori1y or licen:Jing authority that you presently hold or havt! hi.:: id in the pa:;t. For any non~lnsurancc regulatory issuer, id~ntify and provide the nume, nddress and telephone nu1nber of the licensing authurily or regulatory body having jurisdiction over the license (s} issued. lfyour professiontil \il:~nse r1un1ber is your Social Security Nu1nber (SSN) or embeds your SSN or any sequence of n1ore than five nl1mbers that arc reasonably identifiable as your SSN, \hen \Vritc SSN for that portion of the professional license nu1nbcr that is represented by your SSN. (For example, "SSN", "12-SSN-345" or "1234-SSN" (last 6 digits)). Attach ndditional pages if the space pruvidcd is insufficient.

---·· ·-· ·-·--.. -----· -··--·- ------··--·------···-····-···

Organi1.ationllssuer of License: Ozp.et~1;..;,.J__~..,!'r. Address: __ ~ ... r,,,;,,,,,..,_io' L<e·.. ·---·-· Citv: ~~ ...... ,,,. ... ..Jr.) StuLe!Province: c::~ . ..,,r

5 Country: lf <' ;1 Postal Code: · -·-- ..... _ d~l.roF ()..-)./S•i ~ -··· -':2..J.,l~- , -

License Type: J),_Q,_5_. _ _ License Ii: _j '7 3 0 q __ ·---· Date Issued (MM/YY): 0/ J oj. JOI '-f __

Date Expired (MMIYY): {:,/3.!!./?o /{,. Rcawn for Te1111ination: ·---- ·-- _ ·---

Non-h1surance Regulatory Phonv Nun1bcr (ifknO\Vl1): __ _ - ---··---

Organization/Issuer of License: ___ ·---___ _ Address: __ ·--··-· ---· ___ ·---

C'.ity: ·~·--·---···~ Stale/Province: _____ (;ountry: --. -·-. ··~- _Postal Code:-·---

Liccn!ic ·rype: _ ··- ----- l.iccn~e il: __ _ . ____ Date Issued (MM/YY):

Date Expired (MM/YY): __ _ ___ Kea.~on fo1· Termination:

Non-Insurance Regulatory 11hone Nuniber (ifknovvn): _ -------·-- ---·-·-·-----11. 1n responding to the following, if the record has been sc:ateJ. or expung~d, and the atliant has personally verified that

the record wa:;; sealed or expunged, an affiant may respond "no" lo Lhc question. Hav.i.: you cviJr:

a, B!!1;n refused an occupational. professional, or vocalional license or permit by any regulatory authority 1 or any public ud1ninistrative, or govcrn1nenn1l licensing agen.;;.y?

Yes CJ No cz::::J b. l-lad any occupational, protCssional, 01· vocationul license or pennit you hold or have held, been subject to

any judicial, adrninistnitivc, regulatory_, or disciplinary aclion?

Yes C.::=J No [XJ

(§2016 Natioirnl A~~ocia.tion o I" !n"S11rancc Commis~io11ers Rcviso<i 8!1811;\

FORM 11


N/\IC No. FEIN:

c. Been plr.ced on probation or hnd a fine levied against you or yuur occupational, professional, or vocational license or penn1~ in nny judicial, adnlitlistrative} regulatory, 01· disciplinary action?

Yes C=:J No ['g"J d. Bc:cn charged \Vith, or indicted for. any cri1ninal offcnsc(s) o_ther than civil tratTtc offcns.c5?

t:. Pied guilty, or nolo contendcrc, or been cottvicte<l of, any criminal offen.se(s) olher thnn civil rrntfic o!Tunses?

Yes C.:=J No [ZJ f. Had adjudication of guilt withheld, had a sentcuc~ ltnposcd or suspended, had pronouncenH.:nt of a sentence

suspended, or been pardoned, fined, or pla<:ed on probnrion, for any criminal offr:nsc(s)' olher than civil traffic oflCnses?

g. Been subject to a cease nnd d~sist letter or order, or enjoined .• either 1e1nporarily or permancntly1 in any judicial, adn1inis1rative1 regulatory1 or disciplinary action, from violating any federal, state law or law of another count!)' regU!litlng the -bUslness- or-insurance, sc-curitles or ba11king, or froo-1 carrying out any particular-practice or practices in lhe courso of the busit1ess of insurance, securities or banking?

Yes [_ J No [XJ

h. Been1 within the last ten (10} years, a. party to any civil action involvjng dishonesty, breach of trust, -0r a financial dispute?

Yes c:::.::J No IXJ i. Had a finding made by the Comptroller of any state or the Federal Government that you have violah:d any

provisions of s111al\ lL,nn laws, banking or trust company !a\vs, or credit union laws1 or thac you have violated any nJle or regulation lawfully n1adc by the Con1ptroller of any state or the fcdi.::ral Goveni1nent?

Yes c:::.::J No CZJ j. Had a lien or foreclosure action filed againsl you or any cnlity \-Vhile you were associated with that entily?

Yes c·J No CXJ If the response to any question above is yes, pli:af;c provide details inc\J.1ding dcltes, locations, disposition, etc. Attach a copy of lhc: co1nplaint and filed adjudication or settlement us oppropriatc.

--- _ .. ______ _ -------·---------12. List any entity subject to regulation by an instirance regulatory authority that you control directly or indirectly. The

tcnn ncontroP' (including the terms ••controlling1" "controlled by'' and 11under common control \Yith") means the possession1 direct or indirect, of the power to direct or cause the direction of the man.agentcnt and policie.s or tl person, \1ihcther through the ownership of voting securities, by contract other than a comn1ercial contract for goods or non-managen1ent se1vices, or otherwise, unless the power is the l'esult of an official position Vi1ith or corporate office held by the person. Control sh•ll be presumed to exist if •ny person, directly or indirectly, owns, con1rols,

(92016 NaLional Associntion of Insurance CommL5sion~r~ 4 Revised R/18/14

FORMlt

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Applicant Co1npany Nan1e: l11c Dentists Insurance Co1npuny NAlC No. 40975 FEIN: 94-2698799

holds with the power to vole, or holds proxies represtnting, ten percenl (10o/o) or more of the vot-ing securitles of any other pcrson . ._....,.------

____ ,__ ,}__o_VJ_e_._ .. __ _______ _

------··--,-·· ----lfany of the stock is pledged or hypothocated in a11y way, give details._,. _____ _

13. Do [\Villi you or me1nbers of your irnn1ediat~ family individually or cu1nulatively subscribe to or own, beneiich1lly or of r~cord> 10°/o or n1or~ of the outstanding shares of b'.tock of any entity subject to regulation by an in::Hirancc reguh.1lory authority, or its affilicnes? An "'affiliate" of, or person "affiliated'' \Vith, a specific person, is a person that directly, or indirectly th.rough one or n1ore intermediaries, controls, or ls conlrolled by, or is under common control 1Nith> lhe person specified.

YcsCj NoCZJ

If yc::i, please identity lhc cotnpany or cornpanies in which the cumulative stock holdings reprusent I Oo/u or more of the outstanding voting securities.

--------------· ---·· ------- -------··--·----------------

If any of the shares. of stock a.re pledged or hypotltccated in any 'vay, give details.

14, Have you ever been alljudged a bankrupt?

lf'y~s. provide details: ~ __ _

·---··--------

15. To your knowledge has any con1pany or entity for which you were an officer or director, trustee, l11vcstn1cnL '-"01n1niuee 1netnbcr, key 1nanagenlc11t e1nployee or controUing stockholdtr1 had any of the fol\o\.Ving events occur while you served in such capacity?

a. Been r~rused a pcnnit, license, or certificate of authority by any regulatory authority, or govemmcntallicensing agency?

Ye> C:=J No LZJ b. Had its pem1it, license, or ci..:rtificote of authority suspended, revoked, canceled, non-rcnc\i,red, or ~ubjccted

to any judicial, ad1ninislrativc, regulatory, or disciplinary action (including rehllbllitation, \iquidntion, rcceive.rship, conservatorship, tecteral b..111kruprcy proceeding, !)late insolvency, sLipet-vision or any allier sin1llar rroceeding)?

Yes I J No [)2'.J c. Deen placed on probation 01· had a fine le.vied against it or against its permit, liconsti, or certificate or

authority in any civil, crin1inal, adminlsLrativc, regulatory, or disciplinary action?

Yes ~I No CZJ

©1016 Niitional A::;sociarion of ln:-;uruncc Commis'.iionC'rS 5 Revi>cd Rll &114

FORM 11


If the onswer lo any of the above is yes, please indicate a11d give details. When responding to questions (b) and (c), afftnnt shoutd also include any cvt:nt~ within t\velvc (i2) 111onths after h~s (Jr her departure fro1n the cntiLy.

---------·--·--------

·---~---· ··---Nott::; If an affiant has any doubt about the accuracy of an. ansvrer, the ql1estion should be answered in the positive

and an expl~nation provided.

Dutedand signed this.~ dayof_:f.,f)e. 20 IL al ('ore!"" ... C:.,,,;:. . I hereby certify under penally of pedury lhat J a1n acting on nty O\Vll behalf nnd ·that the foregoing; state1nents arc true and co1Tect to lhc bCst of my knowledge and belief.

~"':..--:< ' ~·~==::::::=-(Signature of Aftiont)

Siale of:~{_~"--- ___ -County of;

The tOregoing instrument ·was nckn0\,\1ledged before 111e this __ day of·------' 20 __ by ____ ·----~

and:

who ts pcrson<illy kn<l\\'11 LO me 1 (Jr

vvho produced the following idcntificati-0n: ____ .... ~-·

[SEAL]

©2016 Nttlional Associ<1tio11 of insurance Comn\issioners

Notary Public

Printed-Notary -Name ----

---·-------··· -·-·----·-My Comn1ission Expires

Rcvi,e<l 8118114 PORM I l

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CAll.IFORNIA JllRAT WITH AFFUANT STATEMENT GOVERNMENT CODE§ 8202 ""~"""rrd<\"'6< .... ~ii.\IO .... l\fltli'i<'.i~~:m\l:MH""'~""""""'""'""'""'""'"""""'""'<Gi'J"""'"""®'l<'lt'l<~"'11<J""'"""""

117See Attached Document (Notary to cross out lines 1-6 below) L See Statement Below (Lines 1-6 to be completed only by document slgner[s], not Notary)

Signature of Document Signer No. 1 Signature of Document Signer No. 2 (if any)

A notary public or other officer completing this certificate verifies only the Identity of the lndivi~~a\ who signed the I document to which this certificate is attached, and not the truthlulness. accuracy, or validity of that doCU11'1lnt. ___ ,. . ---· ··---· -- ·-· ' --

State of California

County of £2/,1 y ,<r 4,,'.,,u .

Seal Place Notary Seal Above

Subscribed and sworn to (or affirmed) before me

on thls~7 day of §i%uM ~ 211".i:i'.>. by . Oate Month Year

(1)~7.fl__'?T'J/~~ (and (2) ··--·· _ ),

Name(s) of Slgner(s)

proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me.

Signatur~~ ~~.e___, Signature of Notary Public

~~~~~~~~~~~~~~OPTIONAL~~~~~~~~~~~~~~

Though this section is optional, completing this informeticm can deter alteration of the document or fraudulent reattachment of this form to an unintended document.

Description of Attached Document

Title or Type of Document:

~·~:~~." ·~

©201~~ ry Association· www.NationalNotary.org • 1-800-US NOTARY (1-800-876-6827) Item #5910

From Parkside Dental 1.951.688,4744 Tue Jun 28 09:50:39 2016 PDT Page g of 16

Applicant Cmnpany Name : TI1e Demists lnsurance Company NAIC No. 40975 FEIN: 94·2698799

BIOGRAPHICAL AFFIDAVIT Supplemental Penm1ml Information

(Print or Trpel

To the extent permitted by law, this affidavit wil I be kept confidential by tl1e state insurance regulatory amhority.

Full name1 adJress1 and telephone nun1ber of the presc11t or proposed entity under '""hkh this biographical statement Is being required (Do Not Use Group Nnmes).

'1]1c Dentists h1su,mt~!liillY UQJK Street. 17"' Flq9~mro!Q,.£:fl 958l4

.lfilllllill ·O (i 1.1

I. Afliant's Full Nanw (Initials Not Acccptllble): First&falr/ Middlo:~JJc: "-~ __ ! _ Last:.L!J.,u;/)/d~,., lF ANSWER IS "NONE," SO STATE.

2, !-lave you ever use.ti at1y other name, including first, middle or lust na1ne,-nlckname, 1naiden naine or aliases?

Yes L=-i No lXJ If yes, give the mison if any, if none indicate such, and provide the full namc(s) and date(s) used.

Beginning/Ending Datefsl Used IMM/YYl

Na1ne(s) BQ\lli.Qn Of none. hl!iicate s11chl Specil'v: t'ltst Middle or Lust Na1ne

----- "··--·--

Note: Date~ provided in res.ponse lo this question nlay be approximate. Parties using this forn1 understand \l1at there co1l\d be an overlap of dates \Vhen transitioni11 ' from one name to another.

3. Affiant 1s Socia\ S~curity Number:_-~-···-·-··

4. (.1overn1nent ldent["ficlttion Nun1bcr lfnot a U.S. Citizen: __ --"·-·-------~-·------ ___ ..

Foreign Stude11t ID# (i!'applicable) '--·--·---.. ---------·--·--·----··

6. Dale uf!3irth: (MMIDJ;i. IVY),; PlacoofBirth, City' t+. ?J. _f "'"!... f!3e-<-c !., State/Province: _C:,, . .c /ofu __ ., ________ Country: __ (i;,.;_i~T ....... ('...[__ __ ..... - ..

7. Name nf Arnant's Sp<mse(it'applicable) : ....... De'};..$( ___ .t!L.JJ...&. +°"--·---··-·--·-8. Lis\ your res1drnces for the last ten (10) years starling with your current address, giving;

©201 (i J\l'lliona\ Association of lnsun111ce Commissioners 7 Revised 8/IB/14

FORNl 11

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From Parkside Dental 1.951.688.4744 Tue Jun 28 09:50:39 2016 PDT Page 10 of 16

Bcgin11ing/Ending Dato.; CMMIY)'.)

--····-·-----

StH1e! Province

N/\!C No. F131N:

u ,___l1_· =SA~-

----·-.-·-·----- -

Nore: Dates provided in response to this question 1nay be approxi111ate, except for current address. Parties using thi_s fnr1n understand lhat there could be an overlap of dates ·when transitloning fron1 one address to another.

Dated and signed this :J.7 "-day or_0.,,a __ , 20..lb at __cero,,., C.::; "·----. I !Jernby certify under penalty of perjury tlu1t I am acting ou my ovvn hchalf and that the foregoing staternents are true and correct to the best ofrny knowledge and belief.

-~~~---~--(Signnture of A ffiant)

Stute of: ________ _ County of: ___ _

The foregoing in~trument was acknowledged before me this __ r!ny of._-~------' 20 ____ by ___ ·~- _,

and:

"vho is personl'l!ly known to me, or

who produced the follo"ving identifici:stion: ___ _ ----·----

(SEAL]

t: /J..ll- octUJ./!}_uC, (!_,,;:} --;JUIZ/f ()lLtL u ·,;s 7- I li'

:fJ20 I 6 Nritional /\~sociation or Insurance Cornmi';)~ioncrs 8

Notary Public

--'"--··· ----·· --·· My Co1nmission Expires

Rt'.-·iscd Ril 8/J 4 FORM It

From Parkside Dental 1.951.688.4744 Tue Jun 28 09:50:39 2016 PDT Page 11of16

CALIFORNIA JUMT WITH AFPIANT STATEMENT GOVERNMENT CODE § 8202 0"""frt>lV 0 JC·J~

E'f'See Attached Document {Notary to cross out lines 1-6 below) CJ See Statement Below {Unes 1-6 to be completed only by document slgner{s], not Notary)

-------· -·---_______ .. ___ _

Signature of Document Signer No. 1 Signature of Document Signer No. 2 Of any)

A nota~ publl~ ~:Othe .. r. -offi.;,,r compieti~g this certl;lcate verifies oniy the ider .• tlty of the individual who sign,;<Lthe J document to which this certificate Is attached, and not the truthfulnes~ accuracy, or validity of that document.

. ·- .,.,....._

State of California

County of ~Jk.

Seal Place Notary Seal Above


on this Ci'? day of IJ.,<. . ./?.& , 20/(p

by t) fate 1

_ ~o~th, Year

{1L .. !rB~~«J. /l)~h?7 {and {2), ___ ---------~ ),

Name(s) of Slgner(s)

proved to me on the basis of satisfactory evidence to be the person{s) who appeared before rne.

11 / SlgnaturJ,.il.-&U4--LL U/l,.-1~

Signature of Notary Public

~~~~~~~~~~~~~~OPTIONAL~~~~~~~~~~~~~~

Though this section Is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. __..-"

Description of Attached Document .......................... --.. ---~· Title or Type of Document: ___ ... - .... :::: __ Document Date:-------

Number of Pages: ..... ~ Sig11erj!ilJ)ther1'ha;:;·Named Above:

""""""'°"'"""'""""""~"""""'°....,., .... """...,."""'"""'"""""""""""'""""""'~"""~ ©201_'14!JN:Wi!:uW-i'olr51arary Association• www.NatlonalNotary.org • 1-800-US NOTARY (1-800-87E-6B27) Item #5910

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Applicant Company Name: The Dontists Insurance Company NAIC No. 40975 FEIN: 94-2698799

DISCLOSURE AND AUTHOIHZATJON CONCERNING BACKGROUND REPORTS (Ali states except Califomia, Mi1111esot11 and Oklalzoma)

This Disclo!::urc a11d Authorization is provided to you in connection with pending or future application(~) of The Dentists lnsuranct Conipany jcOinpany n~irneJ(''Cornpany") for llcensure or a pt:rmit to organize ("Appliclltion") \Vitb a depar\n\ent of insurance in one or more states Vi'lthin the United States. Company desir~s to procur~ a consu1ncr or invvstigative consl1mcr report (or both)("Background Reports") regarding your b~ckground for review by a departinent of insurance in ::1ny state ... vhere Co1npany pursues an Application during lhc: lcnn of your functioning as, or seeking to function as, an officer, rnetnber of the board of directors or other 1nunag.ement r~presontative (' 1Affiant~') of Company ur of any business entities affiliated with Company ("Term or Affiliation") for which a 13ackground Report is required by a department uf insurance reviewing any Applicatlon. Duckground Reports. requeMed pursuant to your authorization below may contain information b~aring on yolu· characte::-, general reputation1 pcrsontil characteristics, inode of living und credit standing. The purpose of such Background Reports \vill be to evuluatc lhe Application and your background as it pertains thereto. l'o the extent required by \aV11

, the Background Reports procured under this Disclosure and Authorizailon will be n1ainhdned as confidentiu I,

You 1nay obtain copies of any Background Reports aboot you from the consutner reporting agency C'CR/\1~) that produces thoi-n. You 1nay also request 1nore infort\1ation about the nature and scope of such reports by submitting a written request to Co1npany. To obtain contttct lntbnnalion rcgurdi11g CRA or to subn1it a \vriHen requ~st 10r tnon: intOr1n11tlon, contucl Hu1nm1 Resources, The Dentists Insurance Company, 1201 K Street, 16'' Floor, Sacramento, CA 95819, (800)733-0634 [company's designated person, positin11 1 or dc1lartmt.!nt1 utld1·ess nnd phonel.

/\ltached for your inf'ormrition i:; a '·Summary of Your Rights Under the Fair Credit Reporling Act."

AUTHOR!ZtlTION: I am crntently an Atliant of Cumpnny as dofinccl above. I have read und understand the above J)isclosure. and by my signature below, I cons~nl to the release of Background Reports to a depart1nen~ or insurance tn any state \vhere Company tiles <lr intends to file an Applicntion, and to the Company, for purposes of'investig,uting 1:1nd revie\.i,ii11g such Application rind n1y status as an Affiant l uuthorizc all third parties who ar~ asked to provide information concerning n1e to coopera1e fully by providing the requesled information to CR.A r~lained by Company for purpt.'ISCs or tl1e foregoing Uackground Reports~ except rcconJs thal have been i;rased or expunged. in accordance '~ith law.

I undc:rsrand that l 1nay revok~ this Authorization at 1u1y lhne by delivering a written revocativn lo Co1npany ;:ind that Co111pany will, in that event, fon.,.ard such revocutiun pro111ptly 10 any CRA tbot either prepul'~d or is preparing. Backgniund Reports under-thi$ Disclosure and Authorization. This Authorization shall remriin in full force and effect \lnli\ the earlit!r Qf (i) the ~x.piration of the Tern1 of Affiliation, (ii) written revocation as described nbove, or (iii) twelve (12) 1nonths follo\ving the date of my signature below.

A true copy of this Disclosure and Authorization shall be valid und have the Sf\tnc rorce und effect us lhe signed original.

i2er,,/d_ 1-1). (11,J}/d.;-"--- _L.cra,.,.1_. C~,_ (Printed Full

/~~---~--- ··-·-(Signature)

State ot' Cllunly of: __

The thrcgoing inslrurnent was ['ICkllO\Y]edg,cd befo"re n1e this --- day or - --- __ , 20 by

-·-·-·---- _ ---------_,and;

who is personally knovvn lo 1ne-, or

\Vho produced the follo\ving identificHlion: __ _

[SEAL.]

J;1 [),U., o:;tUJLfe_/_, off C!Pf!-.IL~~~ clU.. &-"J-7-11.f'

<02016 National Association ut' lnsuntncc Co1nn1i~sioner~

. ---·----·--·-.-- ... --- -· Notary Public

~C\i1::;t:d 8t(8!J.:1 FOR>1 l l


CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§ 1189

.,,~ .~-"""~"""

I A notary public or ~ther officer completing this certificate verifies ~nly the identity of the Individual who signed the l L .. document .t~ which this certificate is ~ttached, ~nd not the truthfulness, accuracy, ~r validil)I of that document. J State ol California )

County of~, ~ ,

on-1f_:J: -/ before me, ~~~_JlMvu/ /UPf!tet-;, Date H;._re /ns7rlf"l!f1" '!'}d Title of ,h(,()ffl(;t/7

personally appeared fil:'({~L 'i-1JYJ __ Neme(s) of Signer(s)

·----· who proved to me on the basis o·f satlsfae1ory evidence to be the person~ whose narne~)('.!sl'11r;r ~-\ibscribed to· the within instrument and acknowledged to me thatdli!lliheftney executed the same in

(!!~ijll-.,efl~heir authorized capacity( I&!!)·, and that by~ignature(G) on the instrument the person.{Jl'J, or the entity upon behalf of which the person(aj acted, executed the instrument ..

Place Notary Seal Above

I certify under PENAL TY OF PERJURY under the laws of the State of California that the foregoing paragraph Is true and correct.

WITNESS my hand and official seal.

Signature d.t.,,t j''dtL (1J2.)(~ Signature of Notary Public

-~~~~~~~~~~~~--oPnONAL~~~~~~~~~~~~-~-

Though this section is optional, completing this Information can deter alteration of the document or fraudulent ~ttachment of this form to an unintended document.


Title or Type of Document: -----------Number of Pages: Signer(s) Other Than Name:g._,,,,10·

Capacity(ies) Claimed by Slgner(sJ Signer's Name: ----· Signer's .Name: D Corporate Officer - Title(s); . ...,....:::._ ·-Cl Partner - lJ Limited D eial

C Corporate Officer - Title(s): ___ _ ' , Partner - :::; Limited D General

I Individual 11 ney In Fact .J Individual ·-: Attorney in Fact ·.J Trustee Guardian or Conservator D Trustee :::J Guardian or Conservator U Other: =.L...--0-----------Signer

C Other: Signer IS Representing: ---------

-~-----"''"'"""""""""'"""'""'""" _____ _ ©2014 National Notary Association· www.NatlonalNotary.org • 1-800-US NOTARY (1-800-876-6827) Item #5907

(

(

From Parkside Dental 1.951.688.4744 Fr1 Jul 29 17:08:57 2016 PDT Page 2 of 3

Applicant Company Name : The Dentis.ts Insurance Company NA!C No. 40975 FEIN: 94-2698799

DISCLOSURE AND AUTHORIZATION CONCERNING BACKGROUND REPORTS (Cu/lfomia)

This Disclosure and Authorization is provided to you In conne<:tion with a pending application of The 0f;ntisls Insurance Company !company namel("Company") for licensure or a pennit to or~anize ("Application") with a department of insurance in one or more states within the United States. Compnny desires to procure a consumer o·r inves(igative consumer report (or both)("Bnckground Reporlli") regarding your backgro"nd for review by any department of insurance in su"h states where Company is currently pursuing an Application, because you are either functioning as, or are seeking to function as, an officer, member of the board of directors or other management representative ("Affinnt") of Company or of any business entities affiliated with Company ("Tenn.of Affiliation") for which a Background Report is required by a department of insurance reviewing any Application. Background Reports will be obtained through Owens Onlille, lnc., 3802 Ehrlich Road, Suite 307, Tampa Florida 33624 !name of CRA, addre,.J("CRA"). Background Reports requested pursuant to your authorization below may contain infon11ation bearing on your character, general reputation, pmonal characteristics. mode of living and credit stat1ding. The purpose of such Background Reports will be to evaluate the Application end your background us ii pertains thereto. To the extent required by law, tho Background Reporrs procured under this Disclosure and Authorization will be maintained as confidential. You may request more info1111ntion about the nature and scope ofllackground Reports produced by any consumer reporting agency ("CR/\") by submitting a written request to Co1111>any. You should submit any such wrluen request for more information, to Human Resources, The Dentists Insurance Company, 1201 K Street, Sacramento, CA 95814 (800)733-0634 (company's designuted person, posltior1, or department, address and phone!.

Attached for your information is a "Summary of Your Rights Under the Fair Credit Reporting Act." You will be provided with a copy ofBay Background Report procured by Companyifyou check the box below.

o By checking this box, I request a copy of any Background Report from any CRA retained by Compnny, ut no extra charge.

Under section 1786.22 of the California Civil Code, you may view the file maintained on you by the CRA listed above. You may also obtain a copy of this file, upon submitting proper identification and paying the costs of duplication services, by appearing at the CRA In person or by n1njl; you 1noy ul::io receive a sufl11nary of the file by telephont:. The CR.A. is required to have personnel available to explain your file to you and the CRA must explain to you any coded information appearillg in your file. _If yon appear in person, you may be accompanied by one other person of your choosing, provided that person furnishes proper identification. AUTHORIZATION: I am currenUy an Affiant of Company as defined above. I have read and understand the above Disclosure und by my signature below, l consent to the release of Background Reports to a department of insurance in any state where Company files or intends lo file an Application, and to the Comp1my, for purposes of investigating and reviewing such Application and my status us an Affiant. l authorize all third parties who life osked to provide infom1ation concerning me to cooperate fully by providing the requested information to CRA rctolned by Company for purposes or the foregoing Background Reports, except records that hove been erased or expunged in o.ccordnnce wlth law.

I understand that I may revoke this Authorization at any time by delivering a written revocation to Company and that Company will, in thnt event, forward such revocation promptly to any CRA th11t either prepared or is preparing Background Reports under this Disclosure and Authori"tutiun. In no even1 1 however, wilJ this authorization remain in effoct beyond t\\•elvc (12) months following the date of my signature below.

A ~~e copy o(this Disclosure and Authorization shall be valid and have the same force and effect a~the signed ori mal.

,'2er.,./ci /// 41,,1,11~-10. Caf<>..,, c:· <:;. ~,,,<? . rm c •u ntnc nn c~1 encc ress) /

1 b ---

~ ~ . . ..... -2 .... " ----(S1gn11hire) (Oatc)

Stateof; GJ,/;1.,. Countyof f/,'-'<'1S1d<

The foregoing instrument wus acknowledged before tn\! this_ day of~-------~ 20 by __ _ -Wli0tsfl1:111011ally.Jaln.wnjQ,!:% or

who produced the followiug idCfiiJtfCiillil'i'I:'·_· --~~ ............. ~ .. ------

©2016 Nalionul Association of insurance Commis~IOners

-----~and:

No<ary Public

----·-~=~---Printed Notary Name My Commission Expires

Revised 8118114 FOl\M 11

From Parkside Dental 1.951.688.4744 Fri Jul 29 17:08:57 2016 PDT Page 3 of 3

CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§ 1189 """"""-!l'":fl"'"'"?'"f"'Vffl'Ol9ili .... -li!.O!IH!'Ol!!_F .. •>!il;q,:Oil"'>Qi11.\&MOl~IB-b .. '¢""~ ....... ,., ...... ~--.. :m-t:<r.1'Z""1tll111"'"1ml!Mlrc<r.1'1!1l~~

r-.::;:lary pubHc or other officer completing this certificate verifies only the Identity of the Individual Who signed the ~umen1 to which this certificate Is attached, and not tho truthfulness, acouracy, or Valldlty of that document.

State of California . )

County of R./.r .U ,;,4..edJL.. ) On / ·cf? 9··/[p before m"7·--€A f,,q;..¢. &vb?.P /Ul:/e&Ur t?<<'.L'::.A...;_,,

Data Hara Insert Nam~ and Title o~e Officer

p~rsonally appeared Av.a 4/1 c1.., '-tl). y7·J<~,,.,e'-"-s..fl~O_,,_#_,Jo.._ ____ _ Nama(s) of Slgner(s) ____ _....,..--·--------·--· ···~----------~-·

who proved to me on the basis ot satisfactory evidence to be th~erson(JQ whose name'8) dilhre subscribed to the within Instrument and acknowledged to me that lb.~hey executed fhe same In

dJ}"'~ther/il 1eir-authorized c. apacityOes), and tha. t .t:J~r alfjna.ti.,lia~i on tha-ih$burr1en11he-perSon(51, or the entity upon behalf of which tha paroon,1"1 acted, executed the Instrument.

I certify under PENAL TY OF PERJURY under tile laws of the State of Callfomla that the foregoing paragraph c· Is true and correct.


Signature LZ'eA .?¢~e~.-i.<~d£7 . Slgnaturo of Notary f>ublio

Place Notary Seel Above -------------OPTIONAL-------------

Though t/Jis section is optional, completing this Information can dater alteration of the document or frauctu/ent reattachment of this form to an unintended document.

Description of Attached Document Title or Type of Document:Ds&c11.<iat,a• ,_e autluyl.~otl~ment Date: /· ;).. q . ./(,> Number of Pages: (17'-f Slgner(s) Other Than Name({ Above: ------·--:,-----

Capa<iltyOos) Claimed by Slgner(s) ./ Signer's Name:-·-~ L_ Signer's Name: -·--;r"'--------U Corporate Officer - Title{s): O Corporate Officer D Partner - 0 Limited - eneral O Partner - O L ed O General 0 Individual 0 may In Fact O Individual D Attorney In Fact 0 Trustee Guardian or Conservator D Trustee 0 Guardian or Conservator 0 Other: o Otha Signer Is resenting: Sig Is Representing: ---------

~-- ( ©2014 National Notary Assoc;iatlon • www.NallonalNotary.org • 1-800·US NOTARY (1·800·876·6827) Item #5007 ...

Applicant Company Name: The Dentists Insurance Company NAfC No. 40975 FEIN: 94-2698799


To the extent permitted by law, this affidavit will be kept confidential by the state insurance regulatory authority.

(Print or Type)

Full name, address and telephone number of the present or proposed entity under which this biographical statement is being required (Do Not Use Group Names).

The Dentists Insurance Company I 20 I K Street. 17'" Floor Sacramento. CA 95814

.ffi00l733-0634

In connection with the above--nan1ed entity, l herewith n1ake representations and supply ittfonnation about 1nyself as he1·einafter 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.

1. Affiant's Full Name (Initials Not Acceptable): First: BI) t\ V\ Middle:_

2. a. Are you a citizen of the United States?

Yes IY~ Nol'-_ _,

b. Are you a citizen of any other country?

Yes jX I Nol L -~ ~

If yes, what country? ____ .,.r_>'<cco.._,· -"--'C..."''"'e:...=----·----

3. Affiant's occupation or profession:. __ _,_,,_,e.~·.!:"'-"='·_,_f-____________________ _

4. Affiant's business address: I 8"ro '1 )Y1 A fj. "- oCt "- s· ·f- ·

Business telephone: 714 9& Z.. 2.4 J ?~ Business Email:

A"''"+"~"' voll"y , cA'i't ':)-<l&"

BM D (j) .S (I'. r no 11-. s (e. vt f1,,, • u, '""

5, Education and !raining:

Col loge/University City/State Dates Attended (MM/VY) Degree Obtained

(J, 6 f tJei-rc.sf.:t, ,,f- L,"c.~i"'"' L'" i:..1 ~; /'1eJ.rcd·k°' I/ i 'l'i!I > ·-

Graduate Studies College/University City/State Dates Attended (MM/VY) Degree Obtained

Other Training: Name City/State Dates Attended CMM/YY) Degree/Ce11ification Obtained

Note: If affiant attended a foreign school, please provide fu.11 address and telephone number of the college/university. If applicable, provide the foreign student Identification Number in the space provided in the Biographical Affidavit Supplemental Information.

©2016 National Association of Insurance Con11Tlission~rs Revised 8118/14

PORM II

Applicant Company Name:-----·--- NAIC No. ----·------FEIN:

6. List of memberships in professional societies and associations:

7.

Nan1e of Society/ Association Contact Name

Address of Society/ Association

Telephone Nu_rnber of Society/ Association

~-·i:;i~f'><r(,..

-------·------------------8. List complete employment record for the past twenty (20) years, whether compensated or otherwise (up lo and

including present jobs, positions, partnerships, owner ofnn entity, ad1ninistrator, manager, ope1·ator, directorates Ol' officernhips). Please list the most recent first. Attach additional pages if the space provided is insufficient. It is only necessary to provide telephone numbers and supervisory information for the past ten (I 0) years.

Beginning/Ending Dates (MM/YY): 11'1'1.- - Pm., ... t' Employer's Name:_'!S~.L!'.i tv\ocl'J /-;d-.e.d i J)() (.

Address: /9'/a'1 t11f"J!/bfe1fl d-.City: fku., h.' .... ""!A.£lec$tate/Provlnce: t A:ll-•b:.d( ' <

Countty: __llS Postal Code: 127o¥ Phone:1f'f'14ZZ'(~Offices/Positions Held: owf>-U' 1~1....,1" I

Type of Business: G """ i>&i. h < Jy,, · r Supe1visor/Co.ntact: _ __,t"--'-~-'rr:-t,_, ------------d

Beginning/Ending _.. Dates (MM/YY): _do1lfr - ']."'_l_S __ Employer's Name: ___ f>.~~·1'..,S'----

Address: .,l!j <C/::>t.,.,,,_ e.rl{'i; City: e> ~';. e.. State/Province: _ _,c,_A"''-'" '-'''-----<!?'I u~

Country: . CJ> Postal Code: q 1-- ¥t, !( Phone: !l':t i ~<\' .- • Offices/Positions Held:_}_ flt- ~,7l...,_.-f-,

Type of Business: Supervisor/Contact:._' ____________ _

-----· Employer's Name:

Address: __ _,,""" ________ City: ---------------State/Province: ---------

Country: Phone: _________ Offices/Positions Held:

Type of Business: Supervisor/Contact: __________________ _

Beginning/Ending Dates (MM/YY): __ _

Address: ___________ City: ___ _ -·--- State/Province: _______ _

Country: ___ _ Postal Code: ___ _

Type of Business:

©2016 National AssociaLlon of Insurance Cornn1issionors

Phone: __ __,,.,_Offices/Positions Held: ________ _

Supel'visor/Conlnct: _ _,,,.,,,_ ______ __;:_ _____ _

2 Revised 8/18/14

FORM 11

(

Applicant Company Name : The Dentists Insurance Company NAIC No. 40975

9. FEIN: 94-2698799

a. Have you ever been in a position which required a fidelity bond?

Yes c=I No [s;;:::l

Jfany claims were made on the bond, give details: ____________________ _

b. Have you ever been denied an individual or position schedule fidelity bond, or had a bond canceled or revoked?

Yes I No l:.>;::::l.. lfyes, give details: ______________________________ _

I 0. List any professional~ occupational and vocational licenses (including licenses to sell securities) issued by any public or governmental licensing agency or regulatory authority or licensing authority that you presently hold or have held in the past. For any non .. insurance regulato1y issuer, identify aDd provide the na1ne 1 address and telephone number of the licensing authority or regulato1y body having jurisdiction over the license (s) issued. If your professional license numbe1· is your Social Security Number (SSN) or embeds your SSN or any sequence of more than five numbers that arn reasonably identifiable as your SSN, then write SSN for that portion of the professional license number that is represented by your SSN. (For example, "SSN'', "12-SSN-345" 01· "1234-SSN" (last 6 digits)). Attach additional pages if the space provided is insufficient.

Organization/lssuerofLicense:i;:i,,...b,, ( 6',u.,( J- (I_ A Address: 2-l!J'(J('" ~t;.~ s+- >+- /IT'o

City: $$<-0\~<..~ 6- Slate/Province: __ C-{\~--· ___ Country:_~tl~S., ____ Postal Code: 'J<fr<

License Type: ~ f-d' License #: J !\1::_3,_ ________ Date Issued (MM/YY): _Jj_ u· / /'1 Ff-

Rea.son for ·rennination: Date Expired (MM/YY): _ -------------------Non-ii urance Regulatory Phone Number (lfknown): -----------

Organizntiou/Iss of License: Address: ----------City: --------- Country: _______ Postal Code: ___ _

Date Issued (MMIYY): ____ , ____ _

Date Expired (MM/YY): ___ _

Non-Insurance Regulatory Phone Number (if known):

11. In responding to the following, if the record has been sealed or expunged, and the affiant has personally verified that the record was sealed 01· expunged, an affiant 1nay respond "1101\ to the queslion. J-fave you ever:

a. Been refused an occupational, professional, or vocational license or pennit by any regulatory authority, or any public adn1inistrative, or govern1nental licensing agency?

Yes I No f>'<] b. Had any occupational, professional, or vocational license or pennit you hold or have held, been subject to

any judicial, administrative, regulatory, or disciplinary action?

Yes I No .l2:'SJ

©2016 Nalional Association of Tnsurancc Co1nn1lssloners 3 R(lviscd 8/18114

FORM It

Applicant Company Name : ----------- NAIC No. ---------FEIN:

12.

c. Been placed on probation or had a Ane levied against you or your occupational, professional, or vocational license or permit in any judicial, administrative, regulatory, or disciplinary action'/

Yes'~-~ Nol>'<I d. Been charged with, or indicted for, any criminal offense(s) other than civil traffic offenses?

Yes CJ No~ e. Pied guilty, or nolo contendere, or been convicted of, any criminal offense(s) other tlrnn civil traffic

offenses?

Yes I No r;:'.5<:!.. f. Had adjudication of guilt withheld, had a sentence hnposed or suspended, had pronouncement of a sentence

suspended, or been pardoned, fined, or placed on probation, for any criminal offense(s) other than civil traffic offenses?

Yes ._I_~ Nokl g. Been subject to a cease and desjst letter or order, or enjoined, either tetnporarily or pern1ane11tly, in any judicial,

achninistrative, regulato1y, or disciplinary action, fronl violating any federal, state la\.Y or law of another country regulating the -business of insurance, securities or banking, or from carrying out any particular- practice or practices in the course of the business ofinsul'nnce, securities or banking?

Yes f==-1 No I>s::t h. Been, within the last ten (10) years, a party to any civil action involving dishonesty, breach of trust, or a

financial dispute?

Yes ._I_~ NolXJ i. Had a finding made by the Comptroller of any state or the Federal Government that you have violated any

provisions of small loan laws, banking or trust company laws, or credit union laws, or that you have violated any rule or regulation lawfully made by the Comptroller of any state or the Federnl Government?

Yes I ~--

No t><J j. Had a lien or foreclosvre action filed against you or any entity while you were associated with that entity?

Yes CJ No c><J If the response to any question above is yes, please provide details including dates, locations, disposition, etc. Attach a copy of the complaint and filed ad.Judi cation or settlement as appropriate.

List any entity subject to regulation by an insurance regulatory authority that you control directly or indirectly. The te1·1n "controP1 (including the tenns "controlling," "controlled by" and "under con1mon control with") n1eans the possession, direct or indirect, of the power to direct or cause the direction of the management and policies of a person, whether through the ownership of voting securities, by contract other than a commercial contract for goods or non-manage1nent services, or other\vise, unless the power is the t'esult of an official posiHon with or corporate office held by .the person. Control shall be presumed to exist if any person, directly or indirectly, owns, controls,

©2016 Notionnl Associntiot~ of Insurance Con11nlssioners 4 Revised 8/18114

FORM 11

(

c

(

Applicant Company Name : The Dentists Insurance Company NA!C No, 40975 FEIN: 94-2698799

holds with the power to vote, or holds proxies representing, ten percent (I 0%) or more of the voting securities of any other person·-------------------------------------

If any of the stock is pledged or hypothecatecl in any way, give details. ________________ _

13. Do [Will) you 01· members of your immediate family individually or cumulatively subscribe to 01· own, beneficially or of record, I 0% or more of the outstanding shm·es of stock of any entity subject to regulation by an insurance regulatory authority, or its affiliates? An uaftiliate'1 of) or person "affiliated" with~ a specific person, is a person that directly, or indirectly through one or more intermediaries, controls, or Is controlled by, or is under common control with, the person specified,

Yes I~-~ No I:>'<! lfyes1 please identify the co1npany or cornpanies in which the cu1nulative stock holdings represent IOo/o or 1nore of the outstanding voting securities.

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

14. Have you ever been adjudged a bankrupt?

Yes I~ No [5<]

If yes, provide details:----·---

--------·--------------

15. To your knowledge has any company or entity for which yon were an officer or director, trustee, investment committee member, key management employee 01· controlling stockholder, had any of the following events occur while you served in such capacity?

a. Been refused a pel'rnit, license, or certificate of authority by any regulatory authority, or governtnentallicensing agency?

Yes I~-~

b. Had its pennit, license, or certificate of authority suspended, revoked 1 canceled, non-renevl"ed, or subjected to any judicial, administrative, regulatory, or disciplinary action (including rehabilitation, liquidation, l'eceivership, conservatorship, federal bankruptcy proceeding, state insolvency, supervision or any other similar proceeding)?

Yes I~ No JN c. Been placed on probation or had n fine levied against it 'or against its pennit, license, or certificate of

authority in any civil, criminal, administrative, regulatory, or disciplinary action?

Yes I'-----' No J:.?'4"-

©2016 NaLional Association of Jnsurnnce Con11nissionc1·s 5 Revised 8/18/14

FORM II

Applicanl Company Name : ------------ NAICNo. ----------FEIN:

If the answer to any of the above is yes,.please indicate and give details, When responding to questions (b) and (c), ( affiant should also include any events within twelve ( 12) months after his or her departure from the entity.

---------------------~-·-~ --------------------

Note: !fan affiant has any doubt about the accuracy,ofan answer, the question should be answered in the positive and an explanation provided ..

Dated and signed this ____lJ_ day of dk-= 20 I"_ at ·~ V<?{~ • . I hereby ce1tify under p all pe1jury that I am acting on my own behalf and that the foregoing statements are ~and correct to the best ofmx wle. ge and beli f.

/

(Signature of Affiant)

State of: ----------- Countyof: ---·-·-~----·----·

The foregoing instrument was acknowledged before me this __ day of _____ , 20 __ by ________ _

and:

who is personally known to 1ne, or

who produced the following identifica · n:

[SEAL]

©2016 Nntional Association of lnsurnnct') Coinmissioncrs 6

Notary Public

Printed Notary Name

My Commission Expires

Revised 8/18/14 FORM 11

(

(

CALIFORNIA ALL·PURPOSE ACKNOWLEDGMENT CIVIL CODE § 1189

A notary public or oiher officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

State of California )

County of . DflilVJ@('., )

on 17 ;bA'IJ,'E'.. Vl\v beforerne, Sn\vr\Z1 JO:nc,rYJC!51 V\!Cllv.Y\/ Pu-.bi\c, Date Here Insert Name and Title oHhe Officer

personally appeared __ \3i\0Xl_ _ _J'Q~{if-'~-Ul~n~ed~--I ___ · __________ _

--------- -------~N=Rwm~e-..(s>;-).olSigner(s)_. ______ _

who proved to rne on the basis of satisfactory evidence to be the person(.s) whose name(srTs/aresubscribed to.-the within instrument and acknowledged to me that he/sbeitliEiy executed the same in his/her!tl'iB'ir authorized capacity(ii'is};'and that by j:Jis/her-/.theirslgnature(S(on the instrument the person(sY,or the entity upon beh~lf of which the persof\(sfacted, executed the instrument.

Place Notary Sea/ Above

I certify under PENAL TY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.


Signature ____ f~,-----------Signature of Notary Public

Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document.

Description of Attached Document Title or Type of Document: ]lQi'f-L""f..IJ\.'C::..::"---+""-'.i"'d""rA"'lfc:if,__ Document Date: ~t 3~~(k~~--kl~t&_ Number of Pages: (p Sig er(s Other Than Named Above: ..LOLJ_.!__1._ _________ _

C.apacity(ieslilaimed by Signer(s) Signer's Nam : __________ _

., Corporate fficer - Title(s): ______ _ i Partner 1·.1 Limited : ' General , lndividu I : , Attorney in Fact : Trustef f c; Guardian or Conservator

10th'.( ~~7~------------Signey Is Representing: ________ _

Signer's Name: _________ _ : 'Corporate Officer - Title(s): ______ _ : ' Partner - ! 1 Limited · General ,. : Individual r 'Attorney in Fact

Trustee i] Guardian or Conservator Other: _____________ _

Signer Is Representing: ________ _

,K,'{,R.~.o.gy'QC'Jg{;.~'®'%-'§K.~'§(..~'Q(.'g<.;.~'¥{,.~~'Q{;.~~'q(,.OW:~'%~<..-'C~~~'Y.{.~~~ .... ~'q:(,;.~~~

©2014 National Notary Association· www.NationalNotary.org • 1-800-US NOTARY (1-800-876-6827) Item #5907

Applicant Company Name : The Dentists Insurance Company NAIC No. 40975 PEIN: 94-2698799

BIOGRAPHICAL AFJi'JDA VlT Sn11plemental Personal I ni'ormatlon

(Priut or 'l'vpc\

To the extent permitted by law, this affidavit will be kept confidcutial by the state insurance regulatory authority.

Pull name, address, and telephone number of tl1e present or pl'Oposed eutity under which this biographical statement is being required (Do Not Use Group Names).

The Dentists Jnsun1ncc Co1npany 1201KStreel.17'" Florn:_Sfil;ll!l!!ento. CA 95814

.(!LOO l733-_Q§l4

(

1. Affiant's Full Name (Initials Not Acceptable): First:J3-.(}a...,._ Middle: __ __:=. ___ Last: [vi. ob XJ]l--1(.Ji'ri \ IP ANSWER IS "NONE.," SO STATE.

2. }Jave yon ever used any other name, including firsl., nlidclle or last name, nicknan1e1 1naideo na111r. or aliase..ri?

Yesc=I No~

Jfyes, give the reason ifany, if none indicate such, and provide the full name(s) and date(s) '"ed.

~1ing/E11ding

Date(s)-1/fil&(i)!!M/YY) Hfilll~_(§).

.Specify: Pjrst. Middle or I .~i..'il..Nrun~ Reason Of none, indicate such)

------- (

-----""'""'-----··-· ·-·. -·

···--·----

-~--------------- ':'-, ----""-.,

---------------

------··"-~···-·-·--· -- -·.

Note: Dates provided in response to this question may be apprnxhnate. Parties using this form understand that thet·e could be an overlap of dates when transitioning from one name In another.

3. Affiant's Social Security Number:

4. Government ldentificalion Number ifnol a U.S. Citizen:

5. Foreign Student ID# (if applicable): _ --- --~-·---····· .... ·· .. ·-------~---~---~----------------~--~

~t:~:~~:~:·~~~;MM/DD/YY) :_ -· !:lace nfl3irth, City: __ _i19f "$."~~CwtA.._'t ------. ---·~-~·--- Country: ____ .4~~ ------------'----

Name of Affiant' s Spouse (if applicable) : .l'.h...<t£7'-Jl-->Y.\.--sJ,..'1 I.! l; __ __ 6.

7.

8. List your residences for the last ten (I 0) years stat1ing with you I' current. address, giving:

©2016 Nalional A:'>Socintion of insnrnncc Conunissionrn·s 7 l\cvi,ed 8/18/I 4

f'ORM I I

(

Applicant Company Name:----------

Beginning/Ending Dates (MM/YY)

!2j.k3

State/ Province

NAICNo. FEIN:

Country Postal Code

Note: Dates provided in response to this question may be approximate, except for current address. Parties using this form understand that there could be a11 overlap of dates when transitioning from one address to another.

Dated and signed this _JJ_ day of '}., . - , W.f..1£_ at kJ;,___ Ir... P 1 • ,......, 1 • J hereby

certify un enalty ofperjm that I an~n rny own behalf and that the foregoing st~troe and correct to the b knowleage nd eli ' .

l '-"\ I..-"--"''-"----'---'...-'~.;.._-"_..:::::.-'.,--'~---


State of: ----------County of: --~--·---·-

The foregoing instrument was ackno\vledged before n1e t --~~·-day of ___ . ____ ., 20 __ by ____ _

and:

who is personally known to me, or

who produced the following ide fication:

[SEAL] PLEl\SE SEE ATTA.CHE!J

Al.t.·PU RPOSE ACKNOWLEOG!1ME ~J! CERTIFICATE

©2016 National Association of Insurance Conunissioners 8

Notary Public

Printed Notary Na1ne



CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE § 1189

A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.


County of 0 (?IV) 5 ('.; ) On \ '.:i (Jv.V\1., '],<>!\./ before me, S\'\\Yl\?l ]~V\(\vY\Q~ 1 NOjil.V~ \lV.,\?\IG

Date _ 1. Here Insert Name and Title o"fthe Officer

personally appeared _ ___0tlYI \'Yl_DC!~) ·~rZA~~-fd~1 ___ -___________ _ Name(s) of Signer(s) ------·

who proved to me on the basis of satisfactory evidence to be the person(s)' whose name(s)-ls/are subscribed to the within instrument and acknowledged to me that he/slle/.they-executed the same in his/1'1eF/thelrauthorized capacity(IJ's);and that by,his/i:ler/thetrsignature(sYon the instrument the person(s); or the entity upon behalf of which the person(g) acted, executed the instrument.




Signature « Signature of Notary Public

-------------~OPTIONAL---------~---~


Description of Attached Document Title or Type of Document: 8 i D I'< i col. ' cu!{\ Document Date: ~

Other Than Named Above: ............. Y"_t_A~--------Number of Pages: 2-- Signer(s

Capaclty(ies) Claimed by Signer(s) Signer's Name:~-----------fJ Corporate Of cer - Title(s): ______ _ c I Partner - ·· Limited [J General 1·1 Individual [;Attorney in Fact I I Trustee ?f\ [] Guardian or Conservator

I.I Other: ~1------------Signer Is R presenting: ---------

Signer's Name: ___________ _ I l Corporate Officer - Title(s): _____ _ U Partner - LJ Limited Ci General I] individual []Attorney in Fact I] Trustee U Guardian or Conservator U Other: Signer Is Representing: ---------

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©2014 National Notary Association • www.NationalNotary.org • 1-800-US NOTARY (1-800-876-6827) Item 115907 (

Applicai1t Company Name: The Dentists Insurance Company NAJC No. 40975 FEIN: 94-2698799

DISCLOSURE AND AUTHORIZATION CONCERNING BACKGROUND REPORTS (All states except Caflf<>rnia, Minnesota mu! Oklahoma)

This Disclosure and Authorization is provided to you in connection with pending or future application(s) of The Dentists Insurance Company [company namej("Company") for licensure or a permit to organize ("Application") with a department of insurnnce in one or more slates within the United States. Company desires to procure a consumer or investigative consumer report (or both)("Background Reports") regarding yolll· background for review by a department of insurance in any state where Company pursues an Application during the term of your ftmctioning as, or seeking to function as, an officer, member of the board of directors or other management representative ("Affiant") of Compnny or of any business entities affiliated with Company ("Term of Affiliation") for which a Background Report is required by a department of insurance reviewing any Application. Background Repolts requested pursuant to yom· authorization below may contain information bearing 011 your character, general reputation, personal characteristics, mode of living and credit standing. The purpose of such Background Reports will be to evaluate the Application and your background as it pertains thereto. To the extent required by law, the Background Reports procured under this Disclosure and Authorization will be maintained as confidential.

You may obtain copies of any Background Reports about you from the consumer reporting agency ("CRA") that produces them. You may also req\1est more information about the nature and scope of such repo11s by submitting a written request to Company. To obtain contact information regarding CRA or to submit a written request for more information, contact Human Resources, The Dentists Insurance Company, 1201 K Street, 16 11' Floor, SacJ'amento, CA 95819, (800)733-0634 [company's designated person, position, or depiu·tment, address and phone).

Attached for your information is a "Summary of Your Rights Under the Fair Credit Reporting Act."

AUTHORIZATION: I am currently an Affiant of Company as defined above. I have read and understand the above Disclosure and by my signature below, I consent to the release of Background Reports to a department of insurance in any state where Company files or intends to file an Application, and to the Company, for purposes of investigating and reviewing such Application and my status as nn Affiant. I authorize all third parties who are asked to provide information concerning me to cooperate fully by providing the requested information to CRA retained by Company for purposes of the foregoing Backg1·ound Reports, except reco1·ds that have been erased or expunged in accordnnce with law.

I understand that I may revoke this Authorization at any time by delivering a written revocation to Company and that Company will, in that event, forward such revocation promptly to any CRA that either prepared or is prepnring Background Reports under this Disclosure and Authorization. This Authorization shall remain in full force and effect until the earlier of (i) the expiration of the Term of Affiliation, (ii) written revocation as described above, or (Iii) twelve (12) months following the date of my signature below.

A true copy of this Disclosure and Authorization shall be valid and have the same force and effect as the signed original.

·5:_c;t~{ttC~ (Signature)

State of: ------- County of: -----The foregoing instrument was acknowledged befo · me this __ day of

_______________ ,,and:

\Vho is personally known to tne, or

who produced the following identi

[SEAL]

ation: ------

PloASE SEE A'r!ACHED Al.1.-PURPOSE ACKNOWLEDGEMtMl

CERTIFICATE

©2016 National Association of Insurance Co1nn1issioners 9

(Date)

20 __ by

Notary Public

Printed Nota1y Name

My Co1n1nission Expires

Revised 8/18/ 14 FORM II

CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§ 1189



) County of 0 f lill'J@'C On \Q ;:Ju\"\.l W\J before me, 5\11\Yl !VJ J?i11fl.\'Ylli151 __ j'J1l'JI\i'L_E_l,\,,,,.bu.\"-'-iC __

. Here Insert Name and Title ol'4he Officer Date

personally appeared B\~t>in mo41t-c/nei:H Name(s) of Signer(s)

who proved to me on the basis of satisfactory evidence to be the. person(s} whose name(s)'1's/are' subscribed to the within instrument and acknowledged to me that he/slwt'ttrey executed tt1e same in his/herlthll'lr authorized capacity(i98)', and that by his/hertth~r slgnature(ll} on the instrument the person(s), or the entity upon behalf of which the person\$) acted, executed the Instrument.



WITNESS my hand an~o~al seal.

Signature ~ Signature of Notary Public

~~~~~~~~~~~~~~OPTIONAL~~~~~~~~~~~~~~


Description of Attached Doc\Jment Title or Type of Document: \)\S ~toSu(-{,, J. fh,ct11J Docum7nt Date: /2 ;;furv_, =llo Number of Pages: Signer(s) Other Than Named Above: ~N~_A __________ _ Capacity(ies) Claimed by Signer(s)

Signer's N~: .1 Corporal Officer - Title(s): ______ _ J Partner U Limited [J General ! lndividlJ I U Attorney in Fact

... : Trust.ze [J ·Guardian or Conservator

I 0th'}:-'-'--------------Sign~( Is Representing: -·--

Signer's Name: ___________ _

IJ Corporate Officer - Title(s):. . ..... ---·· U Partner - 11 Limited [J General Cl Individual LJ Attorney in Fact l.l Trustee CJ Guardian or Conservator LI Other: ____________ _

Signer Is Representing: ---------

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©2014 National Notary Association• www.NationalNotary.org • 1-800-US NOTARY (1-800-876-6827) Item #5907 ( ...

(

/ \_

From: Richard Nagy Fax: (905) 964.4006 To: Fax: +1 (077) 8946768 Page 2 of 2806/113'201610:31 AM

Applicant Company Name : The Dentists Insurance Company NAIC No. 40975 FEIN: 94-269&799



(Print or Type)

Full name, address and telephone number of tile present or proposed entity under which this biographical statement is being required (Do Not Use Group Names).

The Dentl&ts Insurance Comnany 1201KStreet17 FloorS00mmento.CA 95814

1800)733-0634

In connection with the above·namod entity, I herewith make representations and supply information about myself as hereinalter 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.

l. Affiant's Full Name (Initials Not Acceptable): Firsl:_RJchard_Middle: __ James_Last:_Nagy ___ _


Yes CKJ Noc=

b. Are you a citizen of any other country?

Yes CJ No QC] lfyes, who! country? ______________ _

3. Affiant's occupation or profession: Periodontist~---------------------

4. Affiant's business address:l22 S. Patterson Ave. #202, Santa Barbara, CA 93111 __________ _

Business telephone: _805-964-8804_ Business Email: [email protected]. __ _

5. Education and training:

CollegelUniver§lty Clly/Stnte Dates Attended (MM/XYl ~· Obtained

Miami UnivQrslty Oxford, OH 0808 to 06182 BA Zoology

~dnnl2 !21lldies C2lle11e/Unive111i!J! Citl!fState Dates Alt~nded (MMIYY} D2gre~ Obained

Qen1al School QbiQ ~!ate University Colyml!u~. QH Q9/8~-Q,'i/ll~ D!2~

Otl1er Training: Name Cjty/State Pates Attended (MMIYYl Degree/Certification Obtaineg

Univcrsitv of Florida Oainesyille, FL 06/8§-06/87 Certillcute om Greater Los An2eles VA Loo Angeles. CA 06/88-05190 Cerljficate Periodontics

Note: lf affiant attended a foreign school, pleas• provide full address and telephone number of the collcge/1.1niversity. If applicable, provide the foreign student Identification Number in the space provided in the Biogrophical Affidavit Supplemental Information.

©2016 National Association oflnsurance Commissioners Revl>ed 8/t 8/t4

FORM 11

From: Richard Nagy fa)<: (806) 964-4006 To: Fax: +1 (877) 8946766 Page '3 of 29 06118'2016 10:'.lt AM

Applicant Company Name:---·--------- NAICNo. --------FEIN:

6. List of memberships In professional societies and associations:

Name of Socioty/t\&1ocialion

American Academy of Periodontology

Western Society of Periodontology American Dental Association

Contact Name

Dr. Aldredge, Pmident

Todd Goldman, Exec Dir

Dr. Summerhays, President

Address of SocietYIAssociation

737N.J\4ichlgan Ave., Suite 800, Chicago, IL 60611

PO Box 1379, Lutz, FL 33548

21lEastChlcago Ave. Chicago, IL 60611-2678

Telephone Number of Socloly/ Association

{312)787 .. 5518

813444-IOll

312.440.2500

7. Present or proposed position with the Applicant Company: Trustee, CDA Board of Directors ----

8. List complete employment record for the past twenty (20) years, whether compensated or otherwise (up to and including present job~ positions. partnerships, owner of'_an entity., admi.nistmtor,. manager, operator, direCtorates or officerships). Please list the most recentfust. Attach additional pages if the space provided is imnfficient. It is only necessary to provide telephone numbers and supervisory lnformatlon for the past ten ( 10) years.

Beginning/Ending Dates (MMIYY):05/98 __ . -Present __ Employer's Name: Richard Nagy, D.D.S. -----------

Address: 122 S. Patterson Ave. #202 __ City: Santa Barbara ____ State!Province: CA ______ _

Country: USA ___ Postal Code: 93111

Type of Business: Dental/Perlodontnl Practice

Beginning/Ending

Phone: 805-964-8804 Offices!Positlons Held: Owner/Periodontist_

Supervisor/Contact: Me -----Dates (MM/YY): l Vll _ - Present_ Employer's Name: Woolf Dental ----------------Address: 9450 Stockdale Hwy, #110 _ City: Bakersfield. _____ State/Province: CA -------

Country: USA ___ Postal Codo: 93311 Phone: 661-665-0SOO Offices/Positions Held: Periodontist __

Type of Business: ~D"""•n~•~•l"'O"'ffl...,.c.,.Q _________ _ Supervisor/Contact: Jerry Woolf, DDS -----Beginning/Ending Dates (MM/YY): 06/90 _ - 11198 __ Employer's Name: Greater Los Angeles V AMC ----------

Addreos: 11301 Wilshire Boulevard ___ City: Los Angeles _____ State/Province: CA ______ _

Country: USA Postal Code: ____ Phone: 310-478-3711 Offices/Positions Held: Periodontal Residency ProgramDireclor and Department Cbairman __ _

Type of Business: _,H"'o..,s.,p,..ltn.,.1.._ ________ _ Supervisor/Contact: Dr. Jeff Pucher --------

Beginning/Boding Dates (MM/YY): __ _ _ ___ Employer's Name: ___________________ _

Address:----------- City: __________ State/Province: ---------

©2016 National Associatitm (lf Insurance Commissioners 2 Revi"d 8/18/14

FORM ti

( \

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(

From: Richard Nagy Fax: (005) 964-4006 To: Fax: +1 (877) B94S766 Pago 4 of 20 0611012018 10:31 AM

Applicant Company Name : The Dentists Insurance Company NAIC No. 40975 FEIN: 94-2698799

Country: ----- Postal Code: ____ .Phone: ____ Offices/Positions Held:--------

Type of Business: Supervisor/Contact: _______________ _

9. a. Have you ever been in a position which requited a fidelity bond?

Yes (:::KJ No C:J If any claims were made on the bond, give details: None --------------

h. Have you ever been denied an individual or position schedule fidelity bond, or had a bond canceled or revoked?

Yes c::J No [D If yes, give details: ____________________________ _

10. List any professional, occupational and vocational licenses (includb1g licenses to sell securities) issued by any public or govenunental licensing agency or regulatory authority or licensing authority that you presently hold or have held In the p .. t. For any non-lns1innce regulatory issuer, identify and proyide the name, address and telephone number of the licensing authority or regulatory body having jurisdiction over the license (s) issued. If your professional license number is your Social Security Number (SSN) or embeds your SSN or any sequence of more tlian five numbers t\1at are reasonably Identifiable as your SSN, then write SSN for that portion of the professional license number that is represented by your SSN. (For example, "SSN", "12-SSN-345" or "1234-SSN" (lost 6 digits)). Attach additional pages If the space provided Is insufficient.

Organization/Issuer of License: California Denial Board __ Address: 2005 Evergreen Street, Suite 1550 _____ _

City: Sacramento __ State/Province; CA _____ Country: USA -~---Postal Code: 95815 __ _

License Type: Dental ___ _ License#: D38098 ____ Datelssued(MMNY): 4/27/1990 ____ _

Date Expired (MM!YY): NA ____ Reason forTennination: _________________ _

Non-Insurance Regulatory Phone Number (if known): ----------------------

Organization/Issuer of License: California Dental Board __ Address: 2005 Evergreen $tree~ Suite 1550 ------

City:Sacramenfo __ State/Province: CA ____ Country: USA ____ PostulCode: 95815 __ _

License Type: Conscious Sedation License#: C290 _____ Date Issued (MMNY): 5/1311995

Date Expired (MM!YY): NA Reason for Tennlnation: ------------------

Non-Insurance Regulatory Phone Number (If known): ----------------------~

l l. In respcndin& to the following, if tl1e record has been sealed or expunged, and the affiant has personally verified that the record was seoied or cxpuoged, an afl'innt may respond "on" to the question. Have you ever:

a. Been refused an occupational, professional, or vocational license or pennit by any regulatory authority, or any public administrative, or govemmcntat licensing agency?

Yes c::J No [R=:J

©2016 NatiQnal Association of Insurance Commissioners 3 Revised 8118114

FORM!!

From; Richard Nagy F~x: (805) 964·4006 To; F1:1x: + 1 (077) 0946766 Page 5 or 2806118f2D161.0:31 AM

Applicant Company Name:------------ NAICNo. FEIN:

b. Had any occupational, professional, or vocational licenso or permit you hold or bave held, been subject to any judicial, administrative, regulatory, or disciplinary action?

Yesi==! No~

c. Been placed on probation or had a fine levied against you or your occupatlona1. pr~fessional1 or vocational license or pennit in any judicial, administrative, regulatory, or disciplinary action?

Yes i==! No [}CJ

d. Been charged wlth, or indicted for, any crimioal offense(s) other tlian civil traffic offenses?

Yes i==! No l:x:=J e. Pied guilty, or nolo contendere, or been convicted of, any criminal offense(s) otl1er than civil traffic

offenses7

Yes c::J No CK::]

f. Had adjudication of guilt withheld, had a sentence imposed or suspended, had pronouncement of a sentence suspended, or been pardoned, fined, or placed on probation, for any cfiminal "offense(s) other than civil ttaffic offenses?

Yes I No l:x:=J

(

g. Been ,ubjcct 10 a cease and desist letter or order, or enjoined, eitller lemporarlly or permanently, in any judicisl, administrative, regulatory, or dlsciplillM)' action, from violating any federal, state law or law of anolb.er country regulating the business of insurance, securities or banking, or from carrying out any particular prectlce or ( practices in the course of the business of insurance, securities or banking? ·

Yes i==! No !JC]

h. Been, within the last ten (10) yours, a party to any civil action involving dishonesty, breach of trost, or a financial disp11te?

Yes c::J No IJCJ i. Had a finding made by tile Comptroller of any state or lb.e Federal Government that you have violated any

provisions of small loan laws, banking or trusl company laws, or credit union laws, or !hal you have violated any !'\lie or reaul•lion \:awfully made by the Comptroller of any slate or ilie Federal Government?

Yes L=:J No IJCJ j, Had a lien or foreclosure action filed against you nr any entity while you were associated with that entity?

Yes L=:J No [}CJ

If the response lo any question above is yes, please provide delalls including dates, locations, disposition, etc. Allach a .copy of tho complaint and filed adjudication or settlement as appropriate.

12. List ony entity subject to regulation by an insurance regulatory authorhy that you contl'ol directly or indirectly. The tenn "control" (including the termc; "controlling." ••controJled by" and '~nder common c:Qntrol with") means the

©2016 Na1ional Association of Insurance CommissionerS 4 Revised 8/18/14

FORM II

(

From: Richard Nagy Fine: (806) 964--4006 To: Fox: +1 (677) 8940706 Page 6 of 2806/18fl010 10:31 AM

.. ;;..., .....


posseuion, direct or indirect, of the power to direct or cause the direction of the management and policies of a person, whether through the ownership of voting securities, by contract other than a commercial contract for goods or non-management services, or otherwise, unless the power ls the result of an official position with or corporate office held by the person. Control shall be presumed to exist if any person, directly or indirectly, owns, controls, holds with the p~wer to vote, or holds proxies representing. ten percent (10%) or more of the voting securities of any other person.__,.,,,."'--------------------------------

If any oftbe stock ls pledged or hypothecattd In any way, give details. Nono ____________ _

13. Do [Will] you or members of your Immediate fllmily individually or cumulatively subscribe to or own, beneficially or of record, 10% or more of the outstanding shares of stock of any entity subject to regulation by an insurance Jllgulatory authority, or Us affiliates? An "affiliate" of, or person "affiliated" with, a specific person, ls a person that directly, or indirectly through one or more intermediaries, controls, or Is controlled by, or is under common control with, the person specified.

Yes c::::::J No QC]

If yes, please identify the company or compauies in which the cumulative stock holdings represent 10% or more of the outstanding voting securities. None.~--------~~----~--~--------~------~~

If any oftbe shares of stock are pledged or hypotltccated In any way, give details.

Non•·-----~----------------------------~~

14. Have you ever boon adjudged a bankrupt?

Yes c::::::J No ~I x __

If yes, provide details: ----------

IS. To your knowledge has any company or entity for which you were an officer or director, trustee, investment committee member, key management employee or controlling stockholder, bad any of the following events occur while you served In such capacity?

a. Been refused a penni~ license, or certificate of authority by any regulatory auU1ority, or govermnentalliconsing agency?

Yes c:::=J No r:x:=J b. Had Its perml~ license, or certificate of authority suspended, revoked, canceled, non-renewed, or subjected

to any judicial, administrnlive, regulatory, or disciplinary action (including rehabililation, liquidation, receivership, conservatorship, federal bankruptcy proceeding, state insolvency, supervision or any other similor proceeding)?

Yes c=J No r:x:=J c. Been placed oo probation or had a fine levied against it or against its perml~ license, or certificate of

authority In any civil, criminal, administrative, regulatory, or disciplinary action?

Yes [==1 No rr:J

©2016 National Assoclalion oflnsuranee Commi8'ioners 5 Revised 8118114

FORM II

From: Rl~hard N;i.gy Fall: (805) 964·4006 To:

Applicant Company Name:-----------

Fall: -+1 (677) 9946766 Page 7 of 28 OB/161201610:31 AM

NAICNo. FEIN:

If the answer to any of the abcwe is yes, please indicate and give details. When responding to queslions (b) and (<), affiant should also include any events within twelve (12) months after his or her departure from the entity. __

Note: If an afliant has any doubt about the accuracy o.f an answer, the question should be answered in the pO>litive and an explanation provided.

Dated and signed this ft day ot,,.-..LJ,.Ll..'14l-~~ 20 Jf£_ at t~ · I Cf- . ! hereby eer!lfy under penalty of perjury that I am actln my own behalf and that the forego mg statements are true and correct to the best of my kn ge am! belief.

State of: ________ _ County of:

The foregoing instrument was aclmowledged before me th· __ day Of.,_ ____ ,, 20 __ by ________ _

and:


who produced the following i

[SEAL]

©2016 National Association of Insurance Commissioners 6

Notary Public

Printed Notary Name


Revised 8/18114 FORM II

(

c

(

From: Richard Nagy Fax: (605) 964-4006 To: Fax: +1 (877) 8946766 Page 6 of 2806/1812016 i0:31 Ml.

CALIFORNIA JURAT WITH AFFIANT STATEMENT GOVERNMENT CODE § 82.02 :X-~,d',{l(',G("~JC;(',(.'('"..t;{'.c{'~..b!'&"~.o:Cb('.c{",c('.c(".c<'~..ci"d'~..c<'~~..accr..cr.c<'.c<'.e<'.c<'~

~ee Attached Document (Notary to cross out lines 1-6 below) /o See Statement Below (Lines 1-Q to be completed only by document slgner[s), not Notary)

Signature of Document Signer No. 1 Signature of Document Signer No. 2 pt any)

A notary public or other officer completing this cerllfloole veriHes only Iha Identity of the Individual who signed the document to which this certificate Is attached, and not the truthfulness, accuracy, or validity of that document.

State of California

County of~ /"MP~o/lp.4

TERR'/ BICKMORE

•

commission 112021485 ~ Notary Public • callloml• i;

Santa Barbara ooun\'/ ~ M comm. Ex Ira• A r 22 2017

Seal Place Notary Sea/ Above

subscribed and sworn to (or affirmed) before me

on this (~day of 17##~ , 20_.a§ by Date Month Year

(1) . _,e,-c:;l::./,...;i~ /V~

proved to me on the basis of satisfactory evidence to be the person(e} who appeared before me.

Though this section Is optional, completing this Information can deter alteration of the document or fraudulent reattachment of this form to an unintended document.


Title or Type of Document; Document Date; _____ _

Number of Pages: __ Slgner(s) Other Than Named Above:-------------lx..~~~~~.(,"4"X,'C(,,~~~~~"Ct.-"c.(...~~'C(,~~~~..v~'C<;,.~~..<.~~

@2014 National Notal)' Association• www.NatlonalNotary.org • 1·600-US NOTARY (1-600·876-6827) Item #5910

From: Richard Nagy ~ax: (806) 964-4006 To: Fax: +1 (B77) 9946766 Page 9 of 28 061181201610:31 AM

Applicant Company Name : The Dentists Insurance Company NAIC No. 40975 FBIN: 94-2698799

BIOGRAPIDCAL AFFIDA VlT Supplemental Personal Informat1on

!Print or Type)

To fue extent permitted by Jaw, this affidavit will be kept confidential by !he state insurance reJ.!lllatory oufuority.

Full name, address, and telephone number of the present or proposed entity under which this biographical statement is being required (Do Not Use Group Names}.

111e Dentists Insurance Company 1201KStreet,17ih Floor Sacramento, CA 95814.

C800W3-0634

l. Affiant 's Full Name (Initials Not Acceptable): First:_Richard _ Middle:_James__ Last: _]'Jagy ___ _ IF ANSWER lS "NONE," SO STATE.

2. Have you ever used any other name, including first, middle or last name, nickname, maiden name or aliases7

Yes c::=J No [x.=J

If yes, give the reason lf any, if none indicate such, and provlde the full name(•) and date(s) used.

Beginning/Ending .Date(s\ Used IMM/YYl

Name Cs\ Specify: Ffhl· Middle o[ Last Name

Reason Of none. indicate such)

Note: Dates provided in rcspoJtSe to !his question may be approximate, Parties using this form understand that there could be an overlap of dales when transitioning from one name to another.

3, Affiant's Social Security Number: ---------------------

4. Government Identification Number if not a U.S. Citizen: None -----------------5. Foreign Student ID# (if applicable): None ----------------------

6. Date ofBirth: (MMIDD/YY): --Place of Birth, City: Lorain ___________ _ State/Province: Ohio Country: USA ____ ,,__ __________ _

"/, Name of Affiant's Spouse (if applicable): Non•----------------------

©2016 National Association of Insurance Commissioners 7 Revised 8118/14

FORMll

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From: RlchardNagy F<1x: (805) 964-4006 To: FaM: +1 (977) 0946766 Page 10of 20061181201610:31 AM

Applicant Company Name:------------ NAICNo. FEIN:

8. List your residences for the last ten (10) years starting with your current address, giving:

Beginning/Ending State/ D~!~~ (MMIYYl Address ~ Province Countrv

12/13-present Goleta CA USA

06/13-12/13 Santa Barbara CA USA

05/06-06/13 Santa Barbara CA USA

&1•1!!1 Cogc --·--·-Note: Dates provided it1 response to this question may be approximate, except for current addreos. Parties using this fonn

understand that there could be an overlap of dates when tmnsltionin from one oddress to onother.

Dated and signed this J:t day of~..tJ.~~~~-· certify unde enalty of perjury d111t I the b • · and belie

State of: _________ County of~-------

who is personally known I

who produced tlt !lowing identification:

EAL] Notary Public

©2016 National Associotlon of Insurance Commissioners 8

Printed Notlll)' Name


Revised 8/18114 FORM II

From: Richard Nagy Fax: (906) 964-4006 To: Fax: +1 (877) 8946766 Page 11 of 28 00/18/Z016 10:31 AM

CALIFORNIA JUllAT WITH AFPIANT STATEMENT GOVEANMENT CODE§ 6202 ~.<J.<'.0<'.&~~-=£<'.&.&.<.'=1<'.t=.<O.<'.<i<'.<:<'~~""~.<.'I)(\{'~=

0 See Attached Document (Notary to cross out lines 1-6 below) 7ee Statement Below (Lines 1-6 to be completed only by document slgnerfs], not Notary)

Signature o Signature of Document Signer No. 2 (if any)

A notary public or other officer completing thls certificate verifles only the Identity of the Individual who signed the documont to which this certificate Is attached, and not Iha truthfulness, accuracy, or vafldlty of that document.

State of California

County of '9"'~ ~!$'1?A~

TERRY UICICMORE Commlaelon * 2021-435 Nolliry Pullllc • Oalllomla f

Sanla eartara County ~ Gomm. Ex r•• A 22, 2011

Sea/ Place Notary Seal Above

Subscribed and sworn to (or affirmed) beforo me

on this L "cffiday of \ZY~ , 2()~ by Date Month Year

(1) 3o/CWA2':P IV~ I

'1ilnd (2) __ -=-----====~-----~· '.. _.-Nam~f S/gner(s-)-

proved to me on the basis of satisfactory evidence to be the persofllerwho appeared before me.

Though this sect/on Is optional, completing this Information can deter alteration of the document or fraudulent reattachment of this form to an unintended document.


Title er Type of Document: ______________ Document Date:------

Number of Pages: __ Slgner(s) Other Than Named Above:------------~~cx:~~~~~{.~~~'9(.~"'l:

©2014 National Notary Association • www.NatlonalNolary.org • 1-800-US NOTARY (1-600-676-6827) Item #5910

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From: Richard Nagy Fal<: (805) 964-4006 To: Fex: +1 (677) 6946766 Paga 12of 2806/18/201610:31 AM

Applican1 Company Name : The Dentists Insurance Company NAJC No. 40975 FEIN: 94-2698799

DISCLOSURE AND AUTHORIZATION CONCERNING BACKGROUND REPORTS (All states except California, Minnesota and Oklalionio)

This Disclosure and Authorization is provided to you in connection with pending or fu1ure appilcation(s) of The Dentists llisurance Company (company name]("Company'~ for Uccosure or a pennlt to organize ("Application'? with a department of insurance in one or more states within the United States. Company desires to procure a consumer or investigative consumer report (or both)("Backgrouod Reports") regarding your background for review by a department of insurance in any state where Company pursues an Application during the term of your functioning as, or seeking to function as, an officer, member of the board of directors or other management representative ("Affiant") of Company or of any business entities affiliated with Company (''Tenn of Affiliation") for which a Background Report is required by a depa(lll1ent of insurance reviewing any Application. Background Reports requested pursuant to your authorizotion below may contain information bearing on your cboracter, general reputation, personal choracter!stics, mode of living and credit standing. The purpose of such Background Reports will be to evaluotc the Application and your background as it pertnins tl1ercto. To the extent required by law, the Background Reports procured under this Disclosure and Authorization will be maintained as confidential.

You may obtain copies ofany Background Reports about you from the consumer reporting agency ("CRA") tl>at produces U1em. You may also request more information about the nature and scope of such reports by submitting a written request to Company. To obtain contact information rcgording CRA or to submit a written request for more information, contact Human Resources, The Dentists Insurance Company, 1201 K Street, 16ih Floor, Sacramento, CA 95819, (800)733-0634 [company's designated person, position, or department, address and phone].

Attached for your information Is a "Summary of Your Rights Under Uie Fair Credit Reporting Act."

AUmORIZATION: I am currently an Afllont of Company as defined obove. I hove rend ond undcratnnd the above Disclosure and by my signature below, I consent to the release of Background Reporta to a depar1mcnt of insuronce in any stale where Company files or intends to file an Application, and to the Company, for purposes of investigating and reviewing such Application and my status as an Affiant. I authodzc oil tbird portics who are asked to provide information concerning me to cnoperole fully by providing the requested infonnotion lo CRA retained by Company for purposes of die foregoing Background Reports, eKcept rc'<:ords that have been erased or expunged in acconlnnce with law.

I understand thnl 1 may revoke till• Allthorizatton al any time by delivering a written revocation to Company and that Company will, in that event, forward such revocn1ion promptly to any CRA that either prepared or is preparing Background Reports under this Disclosure and AuUtorization. This Authorization shall remain in full foc·ce and effect until the earlier of (i) the expiration of the Term of Affiliation, (ii) written revocation as described above, or (ili) twelve ( 12) months following the date of my signature below.

A true copy of this Disclosure and Authorization shall be valid and have the same force and effect ns the signed original

State of:------

The foregoing instrwncnt was

Councy of:-------

this __ day of

See Attached Notarial Document

©2016 N11tionnl Association of Insurance Commissioners 9

' (bate)

20~- by

My Conunission Expires

Revised 8/18114 FORM 11

From: Richard Nagy Fex: (805) 964-4006 To: Fa)(: +1 (877) 8946766 P0ge 13of 2806/181201610:31 AM

CALIFORNIA JURAT WITH AFFIANT STATEMENT GOVERNMENT CODE § 8202 =<-&=~~.<;;<',/l<)Wd'~=&.<'~~-&-.m~

0 See Attached Document (Notary to cross out lines 1-6 below) ~ee Statement Balow (Lines 1-6 to be completed only by document slgner{s], not Notary)

~----.....

Signature of Document Signer No. 1 Signature of Document Signer No. 2 Pf any}

A notary public or other officer completing this oertlfioat& venlies only the Identity of the lndfvldual who signed the document to which this certificate Is attached, and not the truthfulness, accuracy, or validity of that document.

State of Callfornla

County of 7?4Y2'°i"l ~'1,n,4

Seal Place Notary Sea/ Above


on this //t!7day of t~ , 20/tb, by Date Month Year

(1) Rfe#-4-et? .......... ~

(and (2} ___ --==--==.::::::::::===:--i ------~·eme(s'f'6f Slgnerfs}-

proved to me on the basis of satisfactory evidence to be the persoref who app!tared before me.

--------------OPTIONAL--------------Though this section is optional, completing !Ills Information can deter alteration of the document or

mmdulent reattachment of this form to an unintended document. Desorlpllon of Attached Document

Tiiie or Type of Document:------------- Document Date;-----

Number of Pages: __ Slgner(s) Other Than Named Above:------------.~~~~~~~~~~~

~2014 National Notary Association· www.NatlonalNotary.org • 1-800-US NOTARY (1·000·876-6627) Item #5910

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October 18, 2016

Kristofer Graap Holding Company Specialist Company Supervision Division Washington State'O:ffice of the Insurance Commissioner

Re: Form A Statement Regarding Acquisition of Control Of Northwest Dentists Insurance Company By The Dentists Insurance Company - Additional Biographical Information

Dear Mr. Graap:

I currently serve as a trustee of the California Dental Association (CDA), the ultimate controlling person of The Dentists Insurance Company (TDIC). As you know, TDIC proposes to acquire control of The Northwest Dentists Insurance Company (NORDIC).

In connection with the proposed acquisition, I submitted a biographical affidavit, as executed on June 17, 2016, disclosing specific required information. I also understand that there are certain discrepancies between the information reported on my affidavit and information reported to the Washington Office of the Insurance Commissioner (WA OIC) in a background investigation report by Owens OnLine.

Question 11.h of my biographical affidavit asked ifI have been, within the last 10 years, a party to any civil action involving dishonesty, breach of trust, or a financial dispute. Although my answer to this question was no, I am the defendant in a civil lawsuit involving medical malpractice claims that was filed by John Ziliotto and Susan Ziliotto on l/11116 in the Superior Court of Santa Barbara County, CA (case #16CV00081). Since this is currently being litigated and no judgment has been rendered as well as knowing there was no fault on my part I answered no to question 11.h.

In addition, although I did not consider a civil action involving medical malpractice causes of actions to involve dishonesty, breath of trust, or a financial dispute, I now understand that these civil actions should have been disclosed. Further, I understand that in all future biographical affidavits submitted t-0 the WA OIC, I am required to disclose any civil lawsuits of the type described in this correspondence. I very much apologize for the oversight in not including this civil action information on my biographical affidavit, as executed on June 17, 2016.

Thank you very much for your consideration. Should you have any additional questions, please do not hesitate to let me know.

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BIOGRAPIDCAL AFFIDAVIT


(Print or Type)

Full name, address and telephone number of tb.e present or proposed entity under which this biographical statement is being required (Do Not Use Group Names).

The Dentjsts Insurance Comp.111\Y 1201 K Street. J 7•h Floor Sacramento, CA 95814

(800\733-0634

In connection with the above-named entity, I herewith make representations and supply information about myself as herdnafter 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.

l.

2.

Affiant's Full Name (Initials Not Acceptable); First:"liJA~·i ie···Middle:

a. Are you a citizen of the United States?

Yes lb No L=:J b. Are you a citizen of any other country?

Yes c::::J No~ Jfyes, what country? _____ _

Last:_ .. ·~?¥\__.· -~~"'. _t'.'.:-'-ff._-~_--_

3. Affiant's occupation or profession: Oli.'-r t-lt1_L)_,.)'-'1,,,'-ic. .. ,_r.._l_,S,_'·-'-r_· ________________ _

4, Affiant's business address: 3) ?, ) ftj[JI(: i"~C 11 {Ji.ft;· (:rfr'' /.) 3."'(,__'.1_'","''-----

Business telephone: _'jj'.$15) ,~771./ --itri /7 B11siness Email: _Ll1/' j\<\ ,,>.fe1<:' nt<"{ t:/o 5. Education and training:

College/University Degree Ob!filned

. , , . 'ic· Du.I k.1.:J

Grad11~te Studies College/University City/State Dates Attended CMM/YY) . Degree Obtained

d c· i2,f cP-'fi±f~ Ix·1--.n-r1 c. () ., . 11;~dc1'fr) Ci1 1 .. 0 I <n --sio '! T'it{\ . 1~:r f,; ·'-===-'-~;;__---~=~ r / /- I '.1-_f' :J /i.Df.

- ' Note: If affiant attended a foreign school, please provide full address and telephone number of the college/university. lf

applicable, provide the foreign student Identification Number in the space provided in the Biographical Affidavit Supplemental Information.

©2016 National Association of Insurance Commissioners Revised 8/18/14

FORM!!

Applicant Company Name:-------- __ _

6. List of memberships in professional societies and associations:

NA!CNo. F1'1N:

8. List complete employment record for the past twenty (20) years, wMtber compensated or oiherwise (up to and including present jobs, positions, partnerships, owner of an entity, administrator, manager, operator, directorates or officerships). Please list ·the most recent f1tst. Attach additional pages if the space provided is. insufficient. it is only necessary to provide telephone numbers and supervisory information for the past ten ( l 0) years.

TypeofBusiness: t11?.:0IH1~ '?!?Ae{'l~ .. c·· Supervisor/Contact:

Beginninglllnding / . • . t ,-,, .. Dates (MMNY): fA cl j - i, · 15__ Employer's Name: _j·) u·p l) ")···J --·-... •. ~ \'.,q 61 ) 12~ "·'!.::>

' State/Province: ------

Country: -·----- Postal Code: ____ Phone: ____ Offices/Positions Held: A.">"> fl C-i i'~Ti'=r

Type of Business: · fDjJ·f\~i'>~\.;l(1"''1TlC· Supervisor/Contact: .. ·Di? .. , 1' 1 "· ' ? f'- 1 . I ) • .,__,7.),,c:.;r 'l t,..t1-" (~i,_:.,-~:f) (,~ (.~.2..-- <~{ l .. 'SJ).

Beginningillnding { I ·· · · Dates (MMNV): lo 9 J · f.ti Lq ll Employer's Name: IYe. C:A le.I~) 1 /.x: 'Pi::-~.~,·~T.?=·=t)~'"-·----Address: 'j{t;,-··:}"l '?1>).lCtit;'Pvei?.JLtilty: 1l:'Wlt:'(i.,,j cA State/Province: OA

( ,- , .... , ) . "' "' -- ~~-----l ,) (.:, l •!l Country: .\i 'c»{\ ... -- Postal Code: ____ l'hone:)l Zc0f) Offices/Positions Held: IV;~;,(.('.I J~!(=-

Type of Business: f) C:f I.,\(, ' 1" , " '--' "'° ~::;. °t)t;·c N ':1(ll ·-r1·-1 l·""' -:-,f:'···A'".·:-,-1 A,.,,... ''f\.. .., .... "'. ' -, t") Supervlsor/Contac: ---·---------- __ _

Beginnlnglllnding Dates (MM/YY): ___ ---·-- Employer'sName: ___________________ _

Address: ----------- City: __ ., _________ State/Province:

Country: Postal Code: ____ Phone: --·---- Offices/Positions Held; --------

Type of Business:

©2016 National Association of Insurance CommissiOners

Supervisor/Contact:

2 Revised 8/18/14

FORM 11

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Applicant Company Name: The Dentists Insurance Company NAJC No. 40975 FEIN: 94-2698799

9. a. Have you ever been in a position which required a fidelity bond?

10.

Yes r:;'i?J No ._/ _ _,

If any claims were made on the bond, give details: ~":~l_O_J ---------· -------


Yes C:=J No W lfyes, give details: ______________________ . _______ _

List any professional, occupational and vocational licenses (including licenses to sell securities) issued by any public or governmental licensing agency or regulatory authority or licensing authority that you presently hold or have held in the pasi. For any non-insurance regulatory issuer, Identify and provide the name, address and telephone number of the licensing authority or regulatory body having jurisdiction over the license (s) issued. If your professional license number is your Social Security Number (SSN) or embeds your SSN or any sequence of more than five numbers that are reasonably identifiable as your SSN, then write SSN for that portion of the professional license number that is represented by your SSN. (For example, "SSN", "12-SSN-345" or "1234-SSN" (last 6 digits)). Attach additional pages if the space provided is h1sufficient" . . .... . (. , .. , - ~·r"i . ·r··· ,. -.. 1' ,... 11 . ., 1·,i .. ----~"~·-1./.\"l'-> :1 ·c....U~I~-:J~-"~· --·-L+-·~~'"~· _cv~"--------

. . . '')· .. .,.,_. ,...-" (' "'I ["·•, 1J"·O /\i-f'.1~lk'. S ·z· .. (''" .. [.' .·., - "\Vt" .. "'"(- o.•'··'···•·J '.'1' .. f <'')di·;.·,··. I"'_·,··<.,''" ... > Orgamza11on/Issuer of License: l,_l;'l--1 • v <" -v 1 .)•-'I .,u,,_. Address=-~-=-~-, .2.... , , .' · - . " " ' __ _ , .. J c

City: c:)f:it:.°J21~•4L';1!-l'f6 State/Province: 'Ci.\!. ( fi·,i; ·: 1. I itl::ountry; -~'··~i[~:~:i ___ Postal Code: __ C(')'?) l ':S --· 3f.\'::)i

License Type: f)(·'."l•.tlA<' ... License II: < / I Z .(_._/_,<,_~·" __ Date Tssued (MMNY): _i'._'lc~J _/,_._1_1.1/_· ___ _

Date Expired (MMNY): t 0 { I lo I

Non-Insurance Regulatory Phone Number (if known): -~<;)~·· ~1~· ·~'j,....) __ .. ~I ~i~c~{-·--·-·~7_'/_(_ii_'·(~--Organization/Issuer of License: ···---______ Address: __ _

City: ____ _ State/Province: -------Country: .. ___ _ Postal Code: ------

License Type: -----... ·--- License#: _____ ~----- Date Issued (MMIYY):

Date Expired (MMNY): _____ _ Reason for Termination:

Non-Insurance Regulatory Phone Number (if known): -·-------------·-----------

11. in t'esponding to the foll.owing, if the record has been sealed or expw1ged, and the affiant has personally verified that the record was sealed.or expunged, an affiant may respond "no" to the question. Have you ever:

a. Been refused an occupational. professional, or vocational license or pennit by any regulatory authority, or any public administrative, or govemmental licensing agency?

Yes I Nol ,XI b. Had any occupational, professional, or vocational license or permit you hold or have held, been subject to

any judicial, administrative, regulatory, or disciplinary action?

Yes I No Q;-::J

©2016 Notional Association ofJnsurance Commissioners 3 Revised 8/18/14

FORM 11

Applicant Company Name : NAICNo. FEIN:

c. Been placed on probation or had a fine levied against you or your occupational, profussional, or vocational license orpennit in any judicial, administrative, regulatory, or disciplinary action?

Yes C=1 No CJ(l d. Been charged with, or indicted for, any criminal offense(s) otller than civil traffic offenses?

YesL=:J NofTI

e. Pied guilty, or nolo contendere, or been convicted o(, any crimiual offensc(s) other than civil traffic offenses?

Yes[_==:J No~

f. Had adjudication of guilt withheld, had a sentence imposed or suspended, had pronouncement of a sentence suspended, or been pardoned, fined, or placed on probation, for any criminal offense(s) other than civil ·traffic offenses?

Yes I No i::+J g. Been subject to a cease and desist letter or order, or enjoined, either temporarily or permanently, in any judicial,

administrative, regulatory, or disciplinary action, from violating any federal, state law 01• law of another country regulaling the business of insurance, securities or banking, or from carrying out any particular practice or practices in the course of the business of insurance, securities or banking?

Yes L=:J No Q(::::J

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h. Been, within the last ten (10) years, a party to any civil action involving dishonesty, breach of trus~ or a ( , financial dispute?

12.

Yes I No lXJ i. Had a finding made by the Comptroller of any state or the Federal Government that you have violated any

provisions of small loan laws, banking or trust company laws, or credit union laws, or that you have violated any rule or regulation lawfully made by the Comptroller of any state or the Federal Government?

Yes L=:J No l),".::::J j. Had a lien or foreclosure action filed against you or any entity while you were associated with that entity?

Yes C:J No I)( I '

If the response to any question above is yes, please provide details including dates, locations, disposition, etc. Attach a copy of the complaint and filed adjudication or settlement as appropriate.

List any entity subject to regulation by an insurance regulatoty authority that you control directly or indirectly, Tbe term "control" (lncluding the terms "controlling," "controlled by" and "under common control with") means the possession, direct or indirect, of the power to direct or cause the direction of the management and policies of a person, whether through the ownership of voting securities, by contract other than a commercial contract for goods or non-management services, or otherwise, unless the power is the result of an official position with or corporate office held by the person. Control shall be presumed to exist if any person, directly or indirectly, owns, controls,

©2016 National Association of Insurance Commissioners 4 Revised 8/18/14

FORM 11

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Applicant Company Name: The Dentists Insurance Company NAJC No. 40975 FEIN: 94-2698799

holds with the power to vote, or holds proxies representing, ten percent (10%) or more of the voting securities of any other person. __________ ,

If any of the stock is pledged or hypothecated in any way, give details. _________ _

13. Do [Will] you or members of your immediate family individually or cumulatively subscribe to or own, beneficially or of record, I 0% or more of the outstanding shares of stock of any entity subject to regulation by an insurance regulatory authority, or its affiliates? An "affiliate" of, or person "affiliated" with, a specific person, is a person tliat directly, or indirectly through one or more intermediaries, controls, or is controlled by, or is under common control with, the person specified.

Yes [=:J No,~ If yes, please identify the company or companies in which the cumulative stock holdings represent 10% or more of the outstanding voting securities.

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


Yes c:::J No I )( Jfyes, provide details:. __________ _

15. To your knowledge ha.• any company or entity for which you were an officer or director, trustee, investment committee member, key management employee or controlling stockholder, had any of the following events occur while you served in such capacity?

a. Been refused a permit, license, or certificate of authority by any regulatory autl1ority, or govemmentallicensing agency?

Yes L=:J No I )( b. llad its permit, license, or certificate of authority suspended, revoked, canceled, non-renewed, or subjected

to any judicial, administrative, regulatory, or disciplinary action (including rehabilitation, liquidation, receivership, conservatorship, federal bankruptcy prnceeding, state insolvency, supervision or any other similar proceeding)?

Yes I No I )I: ..,,.~~

c. Been placed on probation or had a fme levied against it or against its permit, license, or certificate of authority in any civil, criminal, administrative, regulatory, or disciplinary action?

Yes / No Q(::J

©2016 National Association of Insurance Commissioners s Revised 8/18/14

FORM II

Applicant Company Name:_' ------------- NAlCNo. PEIN:

If the answer to any of the above is yes, please indicate and give details. When responding to questie>ns (b) and (c), ( atfiant should also include any events within twelve (12) months after his or her departure from tbe entity. .

--··----·

Note: If an 1'ffiant has any doubt about tl1e accuracy of an answer, the question should be answered in the positive and an eJ(planation provided.

Dated and signed this .1,_<;:!_1'aay of _,::,,[Lt_>Ll t?"'' 20 l_(a- at _$&!,,.J~J.2j(( Cl 1 C{L . I hereby certify under penalty of perjury jhat·L.llffi acti~ on my own behalf and that the foregoing statements are true and correct to the best of my knowledge.and b.¢lief. ) /}

,/ \ ; . "'"' ~,.~ ,.,~!) ·~/ . II I · 1 -· '""'- ·-·"-' .,,

· 1 ' • (Sign!iiure. of Afri · t)

State of: ________ County of:

The foregoing instrument was acknowledged before me this __ d.ay of ____ _, 20 __ by ____ _

and:


who produced the following identification:

[SEAL]


Notary Public

Printed Notary Name



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ACKNOWLEDGMENT

A notary public or other officer completing this certlftcate verlftes only the Identity or the Individual who signed the document to which this certificate Is attached, and not the truthfulness, accuracy, or valldltv of that document.

State of Callfomla County of ";' "*~ D I £i Ci c )

before me, !Scz",._""",..., j,..... ,"' 1''f!. 1 1-'•rn<\ll.~ p..,..io...1.:.. (Insert name and title of the officer)

personally appeared F.'\. f.\l'-11 ·1r ~. P\l\~.i..:lii·a. who proved to me on the basis of satisfactory evidence to be the persontsr'whose name lslefe subscribed to the within Instrument and acknowledged to me that-l:leJshelthey-executed the same In

-hl6/her/~authorized capaclty()IHr)'; and that by..t:ile/herlthelr-slgnatur~on the Instrument the perso~ or the entity upon behalf of which the person~~cted, executed the Instrument.

I certify under PENAL TY OF PERJURY under the laws of the State of California that the foregoing paragraph Is true and correct.


(Seal)

Applicant Company Name : The Dentists Insurance Company NA!C No. 40975 FEIN: 94·2698799

BIOGRAPHICAL AFFIDAVIT Supplemental Personal Information

(l'rint or Type)

To lhe extent pennitted by law, this affidavit will be kept confidential by the state insurance regulatory authority.

Full name, address, and telephone number of the present or proposed entity under which this biographical statement is being required (Do Not Use Group Names).

l.

The Den!J&ts Insurance Company 1201 KS(Net, l Floor Sacramento, CA95814

{800)733-0634

Affiant' s Full Name (Initials Not Acceptable); FirMeL.~\k( I i:Middle: s u c·· IF ANSWER lS-"NONE," SO STATE.

2. Have you ever used any other nallle, including first, middle or last name, nickname, maiden name or aliases?

Yesc:=J Now If yes, give the reason ifany, lfnone indicate such, and provide the full name(s) and date(s) used.·

Beginnine/Bnding Date(s) Used <MM/YY)

Name(s) Spllcifyj flirst Middle or Last 'Name

Reason llfnone. indi9ate such)

---------·---

Note: Dates provided in response to this question may be approximate. Parties using this fonn understand that there could be an overlap of dates when transitioning from one name to another.

3. Affiant's Social SecurityNumber: _

4. Government ldentificalion Number if not a U.S. Citizen: --------------------s.

6. Date of Birth: (MM/DD/YY) : lace of Birth, City: ()t'kl l/LI~""'. ... _______ _ State/Province: C .Cl t 1' .. ~:):'j .. ,,.,,. '"'-----Country: I J 3

7. Name of Affiant's Spouse (ifapplicable) :_~f~j'-"/t ...... -------------------

8. List your residences for the last ten (10) years starting with your current address, giving:

©2016 National Association of Insurance Commissioners 7 Revised 8118114

FORM l1

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Applicant Company Name:------------

Beginning/Ending Dates (MM/YYl

•i / ,1--<".JO.'.°)- - '?'(f,")t::i>Ji:_

State/ City Province

01n,\l-C)_cfo CA ___

NAICNo. FEIN:

CoU!ll!Y Poslal Code

1.1r;-{\ ------

Note: Dates provided in response to !his question may be approximate, except for current address. Parties using this form understand thul there could be an overlap of dates when transitioning from one address to another.

' . ~... r' .. c·~t;,k. \ ,, - __ , ~- -... J .. -- •') ('' Dated and signed thl• .L;::L: day of -::-'<d--J,lJ~ff-- , 20 , at )i(:, i-..1 I frl\ (: .A-i • T hereby certify unde_ r pen_ ally. ofpe~j ii''llt-I 1.-)lllfi)ctin. g on my own ellalfand that the fo1·egol11glitatements are true and correct to the best of~!)-~ !aJowl,i:>dge d belio/. /

/ , I /1 ( {J-"'----. __ · / > ,.,, ·-" --------

- (Si nature or Affiant)

State of: _________ County of: _________ ~

The foregoing instrument was acknowledged before me this __ day of ______ , 20 __ by ___ _

and:


who produced the following identification: ___ _

[SEAL]

©2016 National Association oflnsurance Commissioners 8

Notary Public

------------------Printed Notsry Name


Revised 8/18114 FORM 11

ACKNOWLEDGMENT

A notary public or other officer completing this certificate verifies only the Identity of the Individual who signed the document to which this certificate Is attached, and not the truthfulness, accuracy, or vaJidllv of that document.

State of Callfomla County of "i'Atv DI 1'><>1 <•

On Jl?Nt;" \ '5, "2-Q IC. before me, f.?.l<l."'"'Oa"' {.pot;!'!. 1-.1<.>"f''l\<1.'1 Pv "'" 1 <.. ~----''-'-""~~'-'-1,i-=--'-~~-

(lnse11 name end title of the officer)

personally appeared IV\~._..,..., 1 *'-" <J. >J 11,l<O'°'~ who proved to me on the basis of satisfactory evidence to be the person ) whose name islftfe subscribed to the within instrument and acknowledged to me that-hefs. /they executed the same Jn

-flla/her/IReit authorized capacity(lest and that by-hiefherMelr slgnatur~ on the instrument the person~ or the entity upon behalf of which the personpir acted, executed the instrument.

I certify under PENAL TY OF PERJURY under the laws of the State of California that the for!!Qolng paragraph Is true and correct.


(Seal)

sRAimoN JOSEPH wof.ii"""·I} Commission II 2061966 t Notary Public • California ~

San Dieoo County -M11 c~~~: .tYpl'.r.s Mi1r 22, 201 e R

• n' -·••,• ,:;•·' • •.,: '•, ' ' ' ' ,:.;

Applicant Company Name: The Dentists Insurance Company NAIC No. 40975 FEIN: 94-2698799

DISCLOSURE AND AUTHORIZATION CONCERNING BACKGROUND REPORTS (All states except C11lifor11la, Mim1esota and Oklahoma)

This Disclosure and Authorization is provided to you in connection with pending or future application(s) of The Dentists Insurance Company [company nameJ("Company") for licensure or a permit to organize ("Application") with a department of iusurance in one or more states within the United States. Company desires to procure a consumer or investigative consumer report (or both)("Background Reports") regarding your background for review by a department of insurance in any slate where Company pursues an Application during the term of your functioning as, or seeking to fnnction as, an officer, member of the board of directors or other management representative ("Affiant") of Company or of any business entities affiliated with Company ("Term of Atliliation") for which a Background Reporl Is required by a department of insurance reviewing any Application. Background Reports requested pursuant to your authorization below may contain information bearing on your character, general reputation, personal characteristics, mode of living and c1·edit standh1g. The purpose of such Background Reports will be to evaluate the Appiicallon and your background as it pertains thereto. To the extent required by law, the Background Reports procured under this Disclosure and Authorization will be maintained as confidential.

You may obtain copies of any Background Reports about you fi'om the consumer reporting agency ("CRA") that produces them. You may also request more information about the nature and scope of such reports by submilling a written request to Company. To obtain contact information regarding CRA 01· to submit a written request for more information, contact Human Resources, The Dentists Insurance Company, 1201 K Street, 16"' Floor, Sacramento, CA 95819, (800)733-0634 [company's designated person, position, or deportment, address and 11l10nej.

Attached for your information is a "Summary of Your Rights Under the Fair Credit Reporting Act."

AUTHORIZATION: I am currently an Affiant of Company as defined above. I have read and understand the above Disclosure and by my signature below, I consent to the release of Background Reports to a department of insurance in any state where Company files or intends to file an Application, and to the Company, for purposes of investigating and reviewing such Application and my status as an Affiant. I authorize all third parties who are asked to provide information conceming me lo cooperate fully by providing the requested information .to CRA retained by Company for purposes of the foregoing Background ReporL•, except records that have been erased or expunged in accordance with law.

I understand that I may revoke this Authori1.ation at any time by delive1ing a written revocation to Company and that Company will, in that event, forward such revocation promptly to any CRA that either prepared or is preparing Background Reports under this Disclosure and Authorization. This Authorization shall remain in full force and effect until t11e earlier of (i) the expiration of the Term of Affiliation, (ii) wrillen revocation os described above, or (iii) twelve (12) months following the date of my signature below.

A true copy of this Disclosure and Authorization shall be valid and have the same force and effect as the signed origh1al.

l'-'lt.'l.l:\od it:"' '3 VL~ '.0'.lk.'J'."c-£ DiY) JV''' ~":)f,,,/·Ui1:i'G (• ,C1;,.,-

-- / .1 , ('~_.,J·. -- :;/-'(Printed Full Nat -1_-0::~~,~-L/_ 1-:, / j I . Ar ; A (',., <>..-

< . t· - . L· -I/"-~··--- _L ' ' (Signature) ·· (Date)

State of: (;~ 1 ; f(}:i::JJ..t+I Coul\ly of: );:.~1,.blfv'·O The foregoing instrument was acknowledged before me this __ day · of 20 by

--·--------------···____,and:


who produced the following identification: ____________ _

(SEAL]


Notary Public

·----------------Printed Notary Name

----------------My Commission Expires

Revised 8/l 8/J 4 FORM JI

ACKNOWLEDGMENT

A notary public or other officer completing this certificate verifies only the Identity of the Individual who signed the document to which this certificate Is attached, and notthe truthfulness, accuracy, or vallditv of that document.

Slate of Callfomla County of <:;:-"'.., l> !lS'<.>i"' )

On _ _,.,J"--,"""'"'""'""-"-1 <"=..>,..., ,.2-:..;o::...cl<P..,__ before me, ~""""'""' Lu:&r;/f2 J Norr.\¥1-1 . R,1~•.1 (., {Insert name and IJtie of the officer)

personally appeared "';L.11\"' • '15' <;::, ·p,.."'-"""'''-who proved to me on the basis ·of satisfactory evidence to be the person whose nam~ lslafe" subscribed to the Within Instrument and acknowledged to me that-l'lelshellf:ley-executed the same In

-his/her/their authorized capacl~. and that byflls/her/tileir signature.!SJ on the instrument the person~r the entity upon behalf of which the perso!l(s11lcted, executed the Instrument.

I certify under PENAL TV OF PERJURY under the laws of the State of California that the foregoing paragraph Is true and correct.


Signature 1 (Seel)

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Applicanl Co1npany Naine :The DentiSL() Insurance Co1npany NAJC No. 40975 PEIN: 94-2698799

BIOGRAPIDCAL AFFIDAVIT


(Print or Type)

Full nan1c, address and telephone nu111ber of the present or proposed entity under which this biographical stat.e1ncnt is being required (Do Nol Use Group Names).

The De11tjsts lnsunmce Comm111)1 l1QJ .. K Street, 17'11 Floor ~.~s:ramenlo,J;:A 9581 'i

(l\00)733-Qjj34

In connection with lhc above~na111cd entity, I herewith 1nake representations and supply inforrnation about 1nysc!f- as hcrcinatler set forth. (Attnch addcndun1 or scparale sheet if space-hereon is insufficient to an3wer any question fully.) IF ANSWER JS "NO" OR "NONE," SO STATE.

I. Al'fiant's Full Na1ne (Initials No1 Acccptable):Firsl: Sanj1.1y, Middle: None Last: Patel

2. a. Are you a citizen of the Un itcd States'?

Yes Q] No [:=:J b. Are youa citizen of any other country?

Yes L.::J No r:x=· 1

If yes. \.Vhat country? __ .

3. Affiant's occupation or profession: Dentist

4. Affiant's business address: Oak Hills Plaza 538 Bailey Rd Pittsburg CA 94565-4304

Business telephone: 925-709-0200 Business E1nail: cooldenl«~Juno.co111

5. l~duca1ion and training:

.~>llege/UIJ.ivcrsity City/State pates Attended (MM/YY) De&r1',l:,\)btnin£>[ Onvcrnmenl Dental Co\lege & Hosp. Amhcdabad, Oujarnt State, India. 0711978-1982 llache\or of Denial Surgery BOS

QiJtduatc Stlidics Collf,!gc/Un iv er® \)ates Attended !MMJYY)

Govcmmenl Dental College & J losp. Amhcdabad, Gl\iarat State, India. 07/J 982-1985 Master of Dental Surgery MDS

Dates Aucnded (!\'1MIYY)

Ad9reft.s o(fore[gn Dental Schol~l:_Civi/ Hospital ('a1111Jt1s, ('ivll Hospital Rfl, Asarwil1 A/1111edahad, (;ujarat 380016, India

Phone: +91 79 2268 2061!

-- ---·· --------·----------- ---Note: If affiant attended a foreign school, please provide full address and telephone nun1ber of the collegc/u11iversi1y. If

applicable, provide the f'orcign stuclc11t Identification Ntnnber in the space provided in the Biographical Affldavit. Supplemental lnt'ormmiun.

tf>2016 Nntionnl Assllciation of ln~uraJH'C! Corn1nis:;.ioncrs Revised 8118/14

FORM 11

Applicant Con1pany Natne : -· NAICNo. FEIN:

6. Lisl of n1e1nberships in professional societies and assllciations:

·NatneJtl' Address of Society/ 8ssociation kQ!lli.H.:L Nan1e Socicti:/Association

120 I K St Sacramento CDA ~.!!_gel.a Ni~.J~e_n .. _ <;:A 95814

ADA 21 I EaslChicago Ave. Chicago, IL 60611-2678

Carol Su1nn1erhays 3460 Hall Lane Lafayette

CCDS Patricia ~~21nely CA 94549

Tel~nbonc Number Qfj;!pcicty/ AssociMi.lli!

1-916-554-4930 - ----.. ----~

1-312-440-2500

"J -925-284-8662

7. Present or proposed position with the Applicant Company: TDJC Board: Director, CDA: Trustee

8. List complete employment record. for the past twenty (20) years. Whether compensated "Of otherwise (lip lO and including present jobs, positions, partnerships, O\.Vl1er of an. entity, administrator, n1ana~cr 1 npcrator; directorates or officerships). Please list the n1ost rc.cenl first Attach additional pages if the space provided ls insufficient. It is only necessary to provide telephone nun1bers and supervisory infonnation for the past ten (10) years.

Beginning/Ending Dates (MM/YYJ:041\ 997-lill date Employer's Name: Sanjay Patel DDS Family Dentistry

Address: 538 Bailey Rd, City: Pittsburg, State/Province: California

Counuy: USA. Postal Code: 94565-4304, Phone: 925-709-0200, Ofliccs/Positions Held: Owner Dentist

Type of' Business: Supervisor/Contact: General Dentistry/ Sanjay Patel DDS

llcginn ing/End ing

Dates (MM/YY): ---······--- Ernployer's ·Natne: - .... ___ _ ---------·------·

Address: __ City: ___ _ State/Province:

Country: Poslal Code: ____ . ___ ,_ Phone: Offices/Positions Held:

'J'ypc of Business: Supervisor/Contncl; --.. -·---- ---· ····- -----Beginning/Ending Dates (MM/YY): --· ···- __ ... _ En1ployer's Name: ----~----

Address: __ City: .. State/Province: ____ _

Cou11l1)1: ___ _ Postal Code: Phone: Offices/Positions Held: ---···---

Type of Business: Supervisor/Contact:--··

Beginning/Ending Dates (M M/YY): --· __ Employer's Name: ---····· ··---- ·----··· ·---- ··-----

Address: ·--City:··---·· .... __ _

Country:. Postal Code: ____ _ Phone:

Tyµc of flusincss: Supervisor/Contact: __ ..

Q.)2016 National /\;;soC'iation of l.t\:-:>urance Co1n1nis;.;ioners 2

State/Province:

Offices/Positions Held: --·-------

Revised 8118114 FORM II

/ \

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Applicant Co1npany Naine :'fhe .Dentists Insurance Cotnpany NAlC No. 40975 l'EIN: 94-2698799

9. a. Have you ever been in a position which required a fidelity bond?

Yes C=:J No QC]

If any claims '~ere n1ade on the bond, give details: __ .. ___ ··--··

b. Have you ever been denied an individual or position schedule fidelity bond, {)f had a bond canceled 01· revoketl'?

Yes I \ No~ If yes, give details: ________ . ___ -------------------

I 0. List any professional, occupational and vocational licenses (including licenses to sell securities) issued by any public or gover11111enlal licensing agency or regulatory authority 01· licunsing authority thal y()u presently hold or have held in the past. For any nonwinsurancc regulatory issuer, identify and provide the nan1e, aclclress anti telephone nun1ber of the !iCensing authority or regulatory body havingjurisdiclion over lhe license (s) issued.If your professlonal license nu1nbcr is your Social Security Nun1bcr (SSN) or e1nbeds your SSN or any sequence of'n1ore than five nu111bcrs thal are reasonably identifiable as your SSN, then wrile SSN for that portion of the professional license nutnbcr that is represented by your SSN. (For example, "SSN", "12-SSN-345" or "1234-SSN" (last 6 digits)). Attach additional pages iflhe space providetl is insufficient.

Orglinizntion/lsSuer of License: Dental Board of Cali!Ornin, Address: 2005 Evergreen Sl STE J 550

City: Sacrn111ento, State/Province: CA 95815-3831, Country: USA Postal Code: 95815-3831

License Type: Dentist, License ff: 3811 J, Date Issued (MM/YY):04/27/i 990

Date Expired (MM/YY): NONF., Reason for Termination: NONE

Non-Insurance Regulatory Phone Nun1bcr (if known): 1-916-263-2300

Organization/Issuer of License: ··--· --· Atldrcss:

City:_ ____ ·--· State/Province: Country: _ Postal Code:

License Type: --· License#: . Date Issued (MM/YY):

Date Expired (MM/YY): _ Reason for l'enninatlon:

Non-Insurance Regulatory Phone Nun1ber (If kno\vn): _.

I I, In respondi11g to the following, if the record has been sea\l!d or expunged, and the affittnt has pt:rsonal\y verified ttlat the rec.:ord was sealed or expunged, an af'fiant n1ay respond :•no" to the question. l·Iavc you ever:

a. Been refused an occupational, professional, or vocational license or permit by any regulatory authority, or any public udn1inist.rativc, 01· govcrnn1ental licensing agency?

Yes L...J No [K \

b. I-lad any occupational, profCssional, or vocational license or pern1it you hold or have held, bc<:n subjcx;t to nny judicia\ 1 adn1inistralivc, regulatory, or disciplinary action?

Yes c--·j No [U

©20 \ 6 National Association \)f Insurance Cmn1nissioners ] Ri.::vi~cd 8/18114

FORM 11

NAIC No.---··· __ _ rn1N:

c I3een placed on probation or had a fine. levied agalnst you or your occupational, professional, or vocational license or pennit in any jud{c.;iaJ, adtninistrative, regulatory, or disciplinary action?

Yes c:=J No QC] d. Bc.:cli charged \Vith, 01' indicted for, any cl'i1ninal offensc(s) other than civil t1·afl:ic onenses?

Yes c:=J No [X=1

e. Pied guilty, or nolo contendere, or been conv"icted of~ any crin1inal t>fl<::nse(s) other than c_ivil tratl1c offe_n~eS?

Yes c:=J No cx:=J r Had acljudication of guilt withheld, had a sentence imposed or susp.cllded, had pronouncement ofa serltence

suspended, or been pardoned. tined, or placed on probation, for a-ny criinii1lll offense(s) other than civi1 traffic one11ses?

Yes c:=J No rx=J g. Been subjecl to a cease and desist le.Her or order, or enjoined, either te1nporarily or permanently, in any judicial,

ad1ninistrativc1 regulatory, or disciplinary action, fro1n violating any federal, state law or law of another country regulaling the business of inKurance,. securities or banking, 01· fro111 carrying out any pa1ticulur practice 01· practices -in the course of the business of insurance, securities or banking?

(

h, Been. within lhe last ten (I 0) years, a party to any civil action illvolving dishonesty, breach of trust, or a c·_ financial dispute?

12.

Yes C:=J No ~

i. Had a finding n1ade by the Con1ptroller of any state or the federal (.iovernn1enL that you have violated any provisions of stnall loan laws, banking or trust conlpany laws, or credil uni'on laws, or that you have violated any rule or regulation lawtlllly made by the Comptroller of any stale or the Pederul Government?

Yes l=::::J No~ j. Had a lien _or foreclosure i1ction filed aguinst you or any entiLy \Vhilc you were associated with that enlily'?

If tire rcsi)onse to any questi()n above hi yes, please ptov1de details including dates, locations, disposition, etc. Attach a copy of the complaint and filed adjudication or settlement as nppropriate.

·----.. -----..... ----· ---- ---· .,. ____ _.., ... ___ ., ·-----···· ~--.. - ---· ···--

List any entity subject to regulation by an insura11c.e regulatory auth<1rity that you control directly or indirectly. The tcnn "control" (including the Lenns "controlling," "controlled by" and "under co1nn1on control with") 1neans the pos!i.ession, direct or it\direcl. of the po\Ver to direct or cause the direction of the 111anage1nent und policies of a person, whether through lhc ownership of voting securities, by contract other lhan a conunercial contract for goods or non-1nanagetnent services, or othen.vise. unless the power is the result of an official position with or corporalc office held by the person. Control shall be presumed to exist if any person, directly or indirectly, owns, controls.

CL:l2016 National /\!'Sl)Ciation of Insurance Co1n1n!:-;sinners 4 Rcvi,cd 8118/14

FORM II

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Applicant Con1puny Narne :'fhe Dentists Insurance Co111pany NAIC No. 40975 FEIN: 94-2698799

holds with lhe po\ver to vote, 01· holds proxies representing, ten percent (I 0°/o) or 111ore of the voting securities of any other person. _________________________________ _

If any <1fthc stock is pledged or hypothecaled in any way, give details._

13. l)o l Will] you or 111en1ber.s of your in11nediate fa1nily individually or cu111ulatively subscribe to or own, beneficially or of rccord 1 I Oo/o or 1nore of the out~tanding shares of stock of any entity suqject to regulation by an insurance regulatory authorily, 01· its affiliates? An <lafftliate" of, or person "affiliated" with, a specific person, is n person that directly, or ·indirectly through one or n1or~ intermediaries, controls, or is controllt:d by 1 or ls under collllllOn control with, the person specified.

Yes [--=:J No !JC--i If yest please id<::ntlf)i the con1pany nrcon1panies in which the cu1nu!utivc stock holdings represent 10°/o or more of the outstanding voting securities.

---------

lfany of the shares of stock are pledged or hypothecated in any \Vay, give details.

I tl. Have you ever been adjudged a bankrupt?

Yes c:--i No I x=-:J If yes, provide details: __ .

---- ----

15. To your knowledge has any coinpany or entity tbr v-.1hich you were an officer or director, trustee, investn1ent con1n1ittee n1en1ber, key 111anage1nc11t e1nploycc or controlling stockholder, hnd any of the following events occur while you served in such capacity'!

a. Been refused a pcrn1it, license, or certificate of authority by any regulatory authority, or governn1cntal~ licensing agency?

No rx __ ,------, Yes L .J I '----1

b. Had its pcrniit. license, or certificate ofaulhority suspended, revoked, canceled, non-rcnc\ved, or subjected to any judicial, adn1inistrativc, regulatory, or disciplinary action (including rehabilitation. liquidalion, receivership, conscrvatorship, federal bankruplcy p1·occeding, state insolvency, supervision or any other sin1ilar proceeding)?

Yes L___] No 1-x-J

c. Geen pluccd on probation or had a t-inc levied against it or against its pern1it, license, or certificate of authority in any civil, cri111inal, ad111inislralive, regulatory. or disciplinary action?

Yes ==i No [i __ J

(\':)2016 National 1\:-::-;odation of' ln::;ura1u.:0 <.."om1nissio1H:r:; 5 Revised 8118114

FORM II

Ap~?lic.ant Con1pany Nan1e ; __ _ ---·"·--·- NAICNo. FEIN: ·--------

If the answer to any of the above is yes. please indicate and give details. When responding to questions (b) and (c), ( afliunt should also include any events within twelve ( 12) rnonlhs atler his or her-departure IT0111 the entity, __

---· --------· ·---·- ---··-.. ---·

--- ----·- ,, ____ ,,.,.,. ___ _ Note: lf an atlia11t_has any doubt about the. accuracy of an answer, the queslion should be answered in the positive

and an explanation provided.

Dated and signed tliis _li_ .. _ day of_ ... ) l.i 1\/t-. ___ 20 J_(,__ al. . f\t. flvw'.,) Cf\- ']_~·u:;-: I hereby certify rnidcr penalty of perju1y-1\iat I am acting on my own behalf and that tho foregoing statements are true and correct to the best of my knowledge and belief.

--- ~~ti.e of Affian_t_) __

State of: (}; \i"fi'.Jx·n ( c1 County of: C'oi.,,'{-ca.. ( i:~f(=c. ·-

A_,.. palllk:., _ _..._lllllialllll -•to --1111 ~of llll todiVldUlt- ......

1111.,..-. ...... lcllUlto ......... II-."""~

Ule~ ..... ..., .... -llJoffllllilC0..-1.

The foregoing instrnment was acknowledged before me this ft day of Ju I\<?..._, 20 \b by ~S.-:i:r.~o."] _r c<:\-e~ _, •Ull\k--

' who produced the following identification: C'. A-l,-l f'. ~)n .;.e,..<; Ljct"S,( __ .

[SEAL] LORESA EVETTE BELLER~ COMM.# 2007&06 rn

~OT ARY PU~LIC- CAtlFORNIA Ul ALAMEDA COUNTY .,

MV 1:1>"11 EXP. FEB. 11, Wl1

~?2016 National AsS()ciation of Insurance Con1n1issioncJ'!'I 6

#0Q/}--&_. <f_ fZx:}dJLe: __ _ Notary Public

_,L,.c) ,-e. .l<t . t;: v el-le. &JI e,... __ _ Printed Notary Name

___ J'.22..~_L'.1 ~ '2N ".J----··My Con1mission .Expires

Revised 8118114 FORM II

(

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Applicanl Co1npany Nm11e :'l"hc Dentists Insurance Co1npany NAIC No. 40975 FEIN: 94-26.98799


(Print or Type)

To lhe extent pcrn1itte<l by lnw, this affidavit will be kept confidendal by the state insurance regulatory authority.

Pull na1nc, address, and telephone nun1ber of lhe present or proposed entity under which this biographical statetnent is being required (Do Not Use Group Names).

The Dentists lnsura11cc C;onlllllJ1Y. J_20 I K Street, 17"' Ploor Sacramento. CA 95814

(800)733-0634

l. Aftiant's Full Name (Initials Not Acceptable): first: Sanjay Middle: None Last: Patel IF ANSWER IS "NONE," SO STATE.

2. Have yoL1 t:Ver used uny other na1nc, including tirst, 1nidc.llc or last nan1e, nicknan1L:, 1naiden nan1c or alittr.;es?

Yes L.-=:J No I iCJ If yes, give the reason if any, if none indicate such, and provide the full na111e(s) and date(s) used.

.Beg inn i ngl.t:nding Date(s)Uscd CMMIYY.l

Name(s'I Re!:k"iOn (lfnonei indicate sue!)) ;lpecify; Pl.rst Mlddl~ PJ: L;L<.;t Nru_u.c.

Note: Dates provided in response to Lhis queslion n1ay be approxi1nate. Parties using this fhrn1 understand thal there could be an overlap of dates 'A1hcn transitioning fro111 one nan1e lo another.

3. Affiant's Social Security Nu1nber-

1. Ciovcrnn1ent ldcntificalion Nun1ber if not a U.S. Citizen:

5. Foreign Student ID# (if applicable): ---~-

6. Date of Birth: (MM/DD/YY):- Place of Birth, City: Ahmedabad

State/Province: Gujarat, Country: India

7. Name of Aftiant's Spouse (if applicable): Rita S Patel

©2016 National A:-:sociation of insurance Con11nissioncrs 7 Rcvi.s~d 8/ l 8/ 14

!'ORM 11

Applicanr Con1pany Nu1nc: ~---- ___ __ NAJC No. FEIN:

8. List your residences for the last ten (I 0) years starting with your current address, giving:

Beginning/Ending Dates IMM/Y.D

1112012 till dale

0711998tilll112012

Address

Alan10

Concord

State/ Provin<;_~

CA

CA

Country

USA

USA

---·---------··----- --------

!'.mtal Code

--

Note: Dates provided in response to this question 1nay be upproxiLnate, except for curronl address, Parties using this forn1 understand that thr.:re could be an overlap of dates when transitiotiing fro1n OJ1e address to unDther.

Dated and signed this -1-R day of_ ,J lJ iV(:: , 20 __ L~- at _ _f)i. /tyv\,O __ CA q ~If <>,:j-- ___ .I hereby certify under penally of pe1:jury that I a1n acting on 1ny own behalf and that the foregoing statcn1ents arc true .and- co1rect lo the best of my knowledge and bcliet:

~~i1.;~~ll!re olAftianl) -- -------

A nolAlry publlcor okolfleorcomptoang tblo oartlllc<lt&

•-Ofliy Ille~ '11 the Individual -elgno<i

c ·' State ot:a { ,.(.,c n 2c tho truthfulnoaa, accurecy; or vaHdttv Of thlt doaumenl

The foregoing instrument was acknowledged before me this __ {_/$_day of_ ~1,p _____ , 20/ (,._ by~/j4--y}l:/eJ . au.d;

1v00--is-pc.i:so11ally.ki1own-~

\\'llo produced the following identification: c~~ .. -~k-~r.~r,,Jc_

[SEALJ

r.~:·' .. LORESA mm BE~LeR( .. , COMM. n 2007906 !Jl /D ' NOTARY PUBUC-CAUFOll.NIA ""' ' Al.M;IEDft CO~tHV itrt, "~' .. ~~ C~~~': EXP. f~B. f1, 20JJ 1

Q'J2016 Natioual Association or lns\ll'ance Con1n1i~sloner.s

~~£.~~,_, __ E_,_f3e{~f~··· ·-Notary Public

.L.1 n:, s~'.:' v'<! 1:±;;.,_B:zJf.er_ Printed Notary Name

----- _O:~.--o2&L7--·-My Co111111issio11 Exp1n:s

Revised 8118/14 FOllM 11

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Applicant Compony Name :The Dentisrn Insurance Company NATC No. 40975 FEIN: 94-2698799

DISCLOSURE AND AUTHORIZATION CONCERNING BACKGROUND REPORTS (All states except California, Minuesota mu/ Oklflltoma)

This Disclosure and Authorization is provided to you in cunncction with pending or fulure applicatio11(s) of The Dentists Insurance Company !company namel("Company") for \icensurc or a permit to organize ("Application") with a department of insurance in one or n1ore stales \Vithin the United States. Co1npany desires to procure a consu1ncr or investigative consu1ner report (or both)(''8ackground Reports") regarding your background for review by a dcpartn1ent of insurance in any state \Vhcrc Co111pnny pursues an Appllcation during' the tcnn of your functioning as, or seeking to funclion as, an ofticer, 1ne1nbcr of the board of direct.ors or other n1anagen1cnt representative C'Affiant") of' Conlpany or of' any business entities affiliated \vith Con1pany ('~Tenn of Affiliation") for which a Background Report is required by a departn1cnt of insurance reviewing any Application. I3ackground Reports t'equested pursuant to your authorization below tnay contain infonnation bearing on your charactcr1 general reputation, personal characteristics, rnode of living and credit standing. The purpose of such Background Reports \Vill be to evaluate the Application and your background as il pertains thereto. To the e.xtent required by law, the Background Reports procured under this Disclosure and Authorizati<)11 will be 111ain1ained as confidcnlial.

You n1ay obtain copies of any Background Reports aboul you fn.1111 the consun1er reporting agency ("('.RA 1') that produces

then1. You n1ay also request 1nore infonnation about the nature and scope: of such reports by subn1itting a \v1·itten r~qucst to Co1npany. To oblain contact information l'egarding CRA or to sub1nit a \Vritten request tbr n1ore infonnntion, conlact Hu1nan Resources, The [)enlists lnsurancc Co1npany, J20J K Street, 16th Floor ,Sacra1nento, CA 95819, (800)733-0634 1cornpany's designated person~ position, or dcpurtn1ent, address and phone}.

Attached for your infonnation is a "Sun1n1ary of Your Rights Under thr;; Fair Credit Reporting Act."

AUTHORIZATION: I am currently an Affiant of Company as defined above. I have read and understand the above Disclosure and by 1ny signature belovv, I Ci.)!lSent to the 1·e\ease of Background Reports to a depann1cnt of insurance in any state when.: Co111pany files or intends to file an Applicatit)Jl, and to the Co111puny, thr p111voses ofinves:t[gating and rcvicvvi11g such Application and n1y status as nn Affiant. I authorize all third parties who are asked to providl' info1·n1ath)n concerning. n1c lo cooperate tlilly by providing the requested inforn1atio11 to CRA retained by Cotnpany for purposes of the foregoing Background Reports, cxcepl records that have been erased or expunged in accordance \Vith law.

1 under!>tand that I n1ay revoke thhi Authorization al any ti111e by delivering a written revocation lo Con1puny and th~al Con1pany will, in that event, fon:val'd such revocation pro111ptly to any CRA that either prepared or is preparing Background Reports under this !)isclosurc And Aulhorizat!on. 'l'his Authorization shall 1·enutin in full force und effect until the earlier of (i) the expirfllion of' the Tenn of Affiliation, (ii) written revocation as described above, or (iii) t\Vc\vc ( 12) inonths follovdng Lf1e date of111y ~dgnaturc: belovv.

A lruc copy of this Disclosure and Authorization shall be valid and have the san1c foi-ce and effect as the signed original.

Sanjay Patel 190 High Eagle Rd, Alamo CA 94507

:Jij_~'-'· -(Printed foll Name and Residence Address)

A "°""I' """"° Of o@ltf - CGOlplellng lllio celflilcoto

- oo1oJ l!lo ldontlly ol tllo lndMdual- llliJned @lo doc- ti> which II* .. If!-le-, ond DOI

-lllo-WU-.1~c0•Yfllklltyo~thnt do<umont. J (Signature)

State or:Ca..l1{or-~!<;__ o (. JJ' .,,,_of C

The foregoing instru1nent \vas a.cknowlcdged before n1e this J_~. day of _ ..::jun r -· , 20l8._ by

Who produced the ICJllO\Ving identitic1:1tion:___Qa., ((·(qr Fl; c.:, lJ r 1, :err

lSEAJ.l .x •. LORESA EVETTE BELLER~ ~ • COMM.# 2007906 UI \fl NOIARY PUOLlC·CAllFORNIA

ALAUEDA COUlllY :; ~:,, t:t'. CDUM EXP ~'.' 1:- 2017 f

©2016 National /\sso\:iati011 or Insurance Con11ni.-:;sloner;;: 9

(I C;;,2$-

\.L)~~ F. &ii. _ ~(1' Notary i'ublic

_ /_ Cl CC I ,;.,. f:.A-&Jk f?xdfL- _ Printed Notary Na111e

_ _(J.2-. - L]..: _ult 7-My Co1nn1ission Expires

Revised 8/18; 14 FORM 11

Applicant Company Name: ___ _ NAIC No. ___ _ FEIN:

©2016 National A~sociation of Insurance Con1missioners JO Revised 8118/ I 4

FORM II

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Applicant Company Name : The Dontist.'1 Insurance Company NAIC No. 40975 FEIN: 94-2698199

DISCLOSURE AND AUTilORIZATION CONCERNING BACKGROUNl'.> REPOXffS (Culij't>tnla)

This Disclosure ond Au!boriz.ation is providod to you in connection with a pending applicatlon of The Dontists lnsuronce COIDpru>y [company numel(''Company") for licensure or a permit to organize ("Application") w:ith a departrnent of insurance in one or more states within the United States. Company desire5 to procure a consumer or investigative consumer report (or both)("Batkground Report$") regarding your background for review by any deportment of insurance in such states where Compnnyis currently pur:ming an ApplicatioJ'.l, because you are either functioning as, or are seeki1>g to fUllctioo as, an officer, member of the board of dlre<:tors or other mlUlagement representative ("Afliunt'') of Companyor of any business entities affiliated with Company ("Term of Affiliation") for which a Background Report is required by a department of Insurance reviewing any Application. Background Reports will be obtained through Owens Online, Inc., 3802 Ehrlich Road, Suite 307, Tampa Fl0tida 33624 [11ame of CRA, addr ... }("CR.A"). Background Reports requested pursuant to your authorization below may contain information bellring on your character, g•no1·al reputation, personal characteristics, mode of living und credit ffilnding. The purpo$11 of such Background Reports wlll be to evaluate tlic Application und your background as it pertains 01ereto. To the extent required by law, the Background Reports procured under this Di$closure Md Authorization will be maintained as confidential. You may roqucst more infonnation about the nature 1md scope ofBackgrotUJd Reports produced by any consmner reporting ageno-y ("CRA") by submitting a written request to Company. You shoilld submit any such written request for more information, to Human Resources, The Dentist.1 lns11mnce Coltlparty, 1201 K Street, Sacramento, CA 95814 (800)733-0634 [comvA•Y'• doslgnatc..J pe ... on, .,osition, or department, address and phoneJ.

Attached for your infonnation is a "Summary of Your Rights Under the Fair Credit Reporting Act." You will be provided with a copy of any Background Report proe<..ed by Company if you cheok the box below.

y By checking this box, I request a copy of ""Y Background Report from any CRA retained by Company, at no e:x:tm ohnrge.

Under section 1786.22 of the California Civil Code, you may view the file maintained on you by the CRA li;ted above. You may also obtai.11 a copy of this file, upon submitting proper identification and paying the costs of duplication sm>ices, by appearing at the CRA In person or by mail; you may also receive a summary of the file by telephone. The CRA is required to have personnel available to explain your file to yon and the CRA must explain to you any coded information appearing in your file. lf you appe;u in person~ you may be accompanied by one e>ther person of your choosing. provldcd that person furnishes proper Identification. AUTHORIZATION: I am currelltly !Ill Aftiant of Companyas defined above. I have read and understaod the above Disclosure and by my signanu·e below, I consent to the release of Buckground Repom to a department of insurance in any state where Companyfiles or Intends to file an Application, und to the Company, for purposos ofinve$\igating and reviewing such AppliMtion and my •tn1U$ U$ an AfllanL I authoriu all third pruti~ wl10 ore asked to provide information concerning me to cooperate fully by provldlttg the requMttd information to CRA retaiued by Companyfor purposes of the foregoing Background Reports, except records that have been erased or expunged Ill accordance with law.

I underst.and that I may revoke this Authori2'.ation at ony time by delivering a written revocution to Company and that Compaity will, in that event, forward such revocation promptly to any CRA thul either prepared or is preparing Background Reports under tl1is Disclosure and Authorization. In no evont, however, will this authorization remnin in cffeot beyond twelve (12) months fbllowing the date of my signature below.

A true copy of this Disclosure and Auth :; A ? A-1-:::L

[SEAL]

©2016 National Association of Insurance Commissioners

1:00 d S88LN

e and effect as the signed original.

frt.J'ffl'\ 6 c fl -7~"'2...-.<..-~

(Date)

_MJ· ~P~rit~1t~ed':7.NFotaryJ.L<~N¥am:ii.,.c11,-.~~~/ ;·

My Commission Expires O 1 / 0 I -z,(ff,D

Revisod 8118114 FORM 11

ll BO BLDZ/SZ/lO

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'l'o the extent penniHed by law, this affidavit will be kept confidential by the state insurance regulatory authority,

(Print or Type)

Pull name, address and telephone number of the present or proposed entity under which this biographical statement is being required (Do Not Use Group Names).

The Denlists Insurance Company 1201 K Street 17'" Floor Sacramento CA 95814

(800)733-0634

In connection with the abovcwna1ned entity, I hcreV11ith 1nake representations and supply information about n1yse!f as hereinafter set tc>1th. (Attach addendum or separate sheet if space hereon is insufficient to answer any q,uestion fully.) IF ANSWER IS "NO" OR "NONE," SO STATE.

1. Atlian!'s Full Name (Initials Not Acceptable): First: Kevin Middle: Christopher l,ast: Roach

2. a. Are you a citizen or the United States?

Yes~ No L=:J b. Are you a citizen of any other country?

Yes [" . __] No ~

If yes, \·Vhat country? ____ --·---------

J. Affiant' s occupation or profession:· Finance/ Accoun1.~nt

4. Atliant's business address:l201 K Street, 14•h Floor, Sacramento CA 95814

Business telephone: (800)232-7645 Business Email: [email protected]


Co I legc/U ni versity City/State Dates Attc11ded (MM/YY) Degree ObLaincd

Santa Clara University Santa Clara CA ·----~0~9~19~0~-~0G~/~9.4 ------~Il~A~-~A~c~co~u~n~ti~n~g

Graduate Studies Collcge/lJ11 iversity Dates Attended (MM/YY) Degree Obtained

-----------~U~C~D~a~v=i'~·---~D~a~v=is~C~A~---~09~/~0~2-~0~3~/0~6 _______ ,_MBA

Other ·rraining: Nan1e Dales Attended (MM/YY) Degrce/Ce1tification Obtained

None.

Note: If affiant attended a foreign school, please provide full address and telephone number of the college/university. If applicable, provide the foreign student Identification Number in the space provided in the Biographical Atlidavit Supplen1cntal Information.

©2016 National Association of Insuranl'e Con1111issioncrn Revised 8/18/14

FORM II

Applicant Company Name : The Dentists Insurance Company NAIC No. 40975 FEIN: 94"2698799

6. List of1nen1berships in professional societies and associations:

Na1nc of Society/ Association Contact Name

Address of fu!£.i.ctyl Association

7. Present or proposed position with the Applicant Company: Chief Financial Officer

-··· ··----------------------

Tulephone Number QI Society/ Association

8. List complete employment record for the past twenty (20) years, whether compensated or otherwise (up to and including- pre.sent jobs, positions, partnerships, owner of an erltity, administrator, manager, operator. directorates or officerships). Please list the most recent first. Attach additional pages if the space provided is Insufficient. It is only necessary to provide telephone numbers and supervisory information for the past ten (I 0) years.

Beginning/Ending Dates (MM/YY):l0/05-Prosent Bmployer's Name: California Dental Association (The Dentists Insurance Company's parent)

Address:l201KSireet,1411' Floor City: Sacramento State/Province: CA

Country: USA Postal Code: 958.14 -Phone {800)232-7645 Offices/Positions Held: Chief Financial Officer; Vice President, Finance; Assistant Vice Presiden~, Finance; Controller.

Type of Business: professional Association with subsi_diaries and affiliates Supervisor/Contact: Peter DuBois

Beginning/Ending Dates (MM/YY): 08101- I 0/05 Employer's Name: Emergency Medicine Physicians

Address: 3300 Douglas Blvd City: Sacramento State/Province: CA

Country: USA Postal Code: 95661 Phone (916) 960-2000 Offices/Positions Held: Financial Analyst; Director of Finance

Type of Business: h\llllt!1care management Supcrvism:/Contact: Bob Spinelli, CFO

Beginning/Ending Dates (MM/YY): I 0100-7/01 Employer's Name: Photopoint Corp.

Address: 250 Montgomery St. City:San Francisco State/Province: CA

Country: USA Postal Code: 94104 Phone: None. Offices/Positions Held: F.inance Manager

·rype of Business: photography products. an9 .<;ervices Supervisor/Contact: Tom Ryan

Beginning/Ending Dates (MM/YY): 05/00 - I 0/00 Employer's Name:Website Pnis, lnc.

Address: 63 I Howard St. City: San Francisco State/Province: CA

Country: USA Postal Code: 94105 Phone: None. Offices/Positions Held: Accounting Manager

Type ofBusiness: web services_ Supervisor/Contact: Craig Winnans

©2016 National Association of Insurance Co1nmissioners 2 Revised 8/ 18114

FORM II

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Beginning/Ending Dates (MM/YY): 05/99-05/00 Employer's Name: Pacific Gateway Exchange, Inc.

Address: 500 Airport Blvd. City: Burlingame State/Province: CA

Country: USA Postal Code: 940 I 0 Phone: None. Otlices/Positions Held: Senior Accountant

Type of Business: telecoin services_ Supervisor/Contact: NIA

Beginning/Ending Dates (MM/YY): 08/97-05/99 Employer's Name: Gap, Inc.

Address: One Harrison St. City: San Francisco State/Province: CA

Country: USA Postal Code: 94105 Phone: None. Ofliccs/Positions Held: Financial Analyst

Type of Business: retail_ Supervisor/Contact: NIA

Beginning/Ending Dales (MM/YY): 11/94-08/97 Employer's Name: Jones, Henle & Schunck

Address: 135 Town & Country Drive City: Danville State/Province: CA

Country: USA Postal Code: 94526 Phone: None. Offices/Positions Held: Senior Accountant

Type of Business: accounting firm_ Supervisor/Contact: NIA

9. a. Have you ever been in a position \Yhich required a fidelity bond?

Yes c:=J No Li:::::]

If any claims were 111ade on the bond, give details:----·


Yes c:=J No I x ~-~

If yes, give details: .. _

-----------------------------·--

10. Lisi any professional, occupational and vocational licenses (including licenses to sell securities) issued by any public or governmental licensing agency or regulatory authority or licensing authority that you presently hold or have held in the past. For any non~insurance regulatory issuer, identify and provide the natne, address and telephone nu111bcr of the licensing authority or regulatory body havi11gjurisdiction over the license (s) issued. If your professional license number is your Social Security Number (SSN) or embeds your SSN or any sequence of more than five numbers that are reasonably identifiable as your SSN, then write SSN for that portion of the professional license number that is represented by your SSN. (For example, "SSN", "12-SSN-345" or "1234-SSN" (last 6 digits)). Attach additional pages if the space provided is insufficient.

Organization/Issuer of License: California Board of Accountancy Address:2000 Evergreen St., Suite 250

City: Sacramento State/Province: CA Country: USA Postal Code: 95815

©2016 National Association of Insurance Co1nn1issioncrs 3 Revised 8/18114

FORM I I


License Type: CPA License License ff: 73822 Date Issued (MMIYY): 06/97

Date Expired (MMIYY): NIA Reason for Termination: NIA

Non-Insurance Regulatory Phone Number (if known): (916)263-3680

11. In responding to the following, if the record has been sealed or expunged, and the afiiant has personally verified that. lhc record \Vas sealed or expunged, an affiant n-1ay respond 11.no" to the question. I-lave you ever:

a. ·Been refused an occupational, professional, or vocational license or permit by any regulatory authority, or any public adn1inistrativc, or governmental ·Jlcensing agency'?

Yes [ __ ~ No I x ~-~

b. Hod any occupational, professional, or vocatio.nal license or permit you hold or have held, been subject to any judicial, administrative, regulatory, or disciplinary action?

Yes I~-~ No [>5_ ___ ]

c. Been placed on probation or had a fine levied against you or your occupational, professional, or vocational license or permit in any judicial, adn1inistrative, regulatory, or disciplinary action?

Yes L_J Nol L -'-~ d. Been charged with, or indicted for, any crin1inal offense(s) other tha11 civil traffic offenses?

Yes ~] Nol~-~

e. Pied guilty, or nolo contendere, or been convicted of, any criminal offense(s) other than civil traffic otfonscs?

Yes LI __ No i:z:::::J f. Had adjudication of guilt withheld, had a sentence irnposed or suspended, had pronouncen1cnt of a sentence

suspended, or been pardoned, fined, or placed on probation, for any criminal offense(s) other than civil traffic offenses?

Yes LI-~ No Li:.::J g, Been subject to a cease and desist letter or order, or enjoined, either temporari1y or permanently, in anY judicial,

ad1ninistrative, regulatory, or disciplinary action, fron1 violating any federal~ state law or la\v ofanolher country regulating the business of insurance, securities or banking1 or fron1 carrying out any particular practice or practices in the course of the business of insurance, securities or banking?

Yes No G::::.::J h. Been_, within the last ten (! 0) years, a party to any civil action involving dishonesty, breach of trust, or a

financial dispute?

Yes CJ No '-'I x_~ i. Had a finding made by the Comptroller of any state or the Federal Government that you have violated any

provisions or s1nall loan laws, banking or trust company laws, or credit union laws, or that you have violated any rule or regulation lawfully made by the Comptroller of any state or the Federal Government?

©2016 National Association of Insurance Conunissioners 4 Revised 8/18/14

FORM II

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Yes C:J No ~I -"-~

j. Had a lien or foreclosure action filed against you or any entity while you were associated with that entity?

Yes C:J No l~x-~

If the response to any queslion above is yes 1 please provide details including dates, locations, disposition, etc. Attach a copy of the complaint and filed adjudication or settlement as appropriate.

Marchj99J - Lake Havasu. AZ. Cited for n1inor in possession of alcohol. Fin_ed $70. _

12. List any entity subject to regulation by an insurance regulatory authority that you control directly or indirectly. The term "control" (including the tenns ·~controlling," \<controlled by" and "under comn1on control \Vith") 111eans the possession, direct or indirect, of the power to direct or cause the direction of the management and policies of a person, whether through the ownership of voting securities, by contract other thun a co1n1nercial contract for goods or non~111anagement services, or nthcnvise, unless the power is the result of an official position with or corporate office held by the person. Control shall be presumed to exist if any person, directly or indirectly, owns, controls, holds with the power to vote, or holds proxies representing, ten percent (10%) or more of the voting securities of any other pcrson.~N~o~n•~·~-------

If any of the stock is pledged or hypothecated in any way, give details. NIA ______________ _

13. Do [Will] you or members of your immediate family individually or cumulatively subscribe to or own, beneficially or of record, !Oo/o or rnore of the outstanding shares of stock of any entity subject to regulation by an insurance regulatory authority, or its affillates? An 11afliliaten of, or person "affiliated" with, a specific person, is a person that directly, or indirectly through one or n1ore intcrn1cdiaries, controls, or is controlled by, or is under co1n1non control with, the person specified.

Yes C:J No [X .. J If yes, please Identify the cornpany or con1panies ln which the curnulativc stock holdings represent IOo/o or n1orc of the outstanding voting securities.

No·----------------------~--~-~------------

If any of the shares of stock are pledged or hypothccated in any way, give details.

NIA.~-----------------------------~


Yes C==1 No LI ~x-~

If yes, provide details: ______ _

15. ·ro your knowledge has any cornpany or entity for 1.vhich you were an officer or director, trustee, investn1cnt cotnmittee mcmbcr1 key inanagen1ent etnployee or controlling .stockholder, had any of the 1-0llo,ving events occur while you served in such capacity?

©2016 National A!i:;ociation or Insurance Con1111bsioners 5 Revi~ed 81!8/l'l

FORM II

Applicant Company Nan1e: The Dentists Insurance Cotnpany NAIC No. 40975

a.

FEIN: 94-2698799

Been refused a pcrmitJ license1 or. ce1tificate of authority by any regulatory authority, or governn1ental-1icensing agency?

Yes LI~~ No G:::::J b. H.ad its permit, licensc1 or certificate of authority suspended, revoked. canceled, non-rencwe~, or subjected

to any judicial, adn1inistrative, regulatory, or disciplinary action (including rehabilitationi liquidation, receivership, consefvatorship, federal bankruptcy proceeding, state insolvency, supervision Qr any other similar proceeding)?

Yes l=:J No G::::::J c. Been placed on probation or had a fine. levied against it or against its permit, license, or certificate of

authority in any civil, crirninalj administrative. rcgulaJory, or disciplinary action?

Yes l=:J No G::::::J If the answer to any of the above is yes, please indicate and give details. When responding to questions (b) and (c), affiant should also include any events within twelve (12) months after his or her departure from the entity.

Note: If an af'iiant has any doubt about the accuracy of an answer, the question should be answered in the positive and an explanation provided.

Dated and signed this 27'1' day of June 2016 at Sacramento, CA. I hereby certify under penalty of perjury that I am acting on my /tehplf and that the l's>segoing statements are true and correct to the best of' my knowledge and belief .

. C c,~ /c-----_ .... ... '"···-----


/' /"

~'tat~- Cou11ty of: --· __ ~ The forego~t-1~nt was acknowledged before n1e this day of ,,,...-.-;·~by , and: ·---......., --~- -- --.. ··-------

who is personally knO\Vtl to me, or

who produced the following identification. ____ .

~/--/ ---........ ~-... --····--.

-----=:....,,__.

See Attached

~/"' Notarization Certificate

©2016 National Association of Insurance Com1n!ssioners 6

-··· ""'NoiilQ Public .... ----P-r-in-te_d_N_oiary ~

------ ·-·----My Cornn1ission Expires

Revised 8/18/14 FORM II

c

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ACKNOWLEDGMENT


State of California County of Sacramento

on June 27, 2016 before me, Jana Wesche, Notary Public

(insert name and title of the officer)

personally appeared Kevin Christopher Roach who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the Instrument.



(Seal)

Applicant Company Name: The DcnLists Insurance Company NAJC No. 40975 FEIN: 94-2698799


(l'rint or Type)

To the extenl permitted by law, this affidavit will be kept confidential by the state insurance regulatory authority.

Full name, address, and tcleplrnne number of the present 01· proposed entity under which this biographical statement is being required (Do Not Use Group Names).

The Dentists lnsJ.Jrance Companv 1201KStreet.17'"Flpgr Sacramento, CA 95814

(800)733-0634

1. Affiant's Full Name (Initials Not Acceptable): First: Kevin Middle: Christopher Last: Roach IF ANSWER IS "NONE," SO STATE.

2. Have you ever used any other name, including first, tnlddle or last natne, nicknamc 1 n1aiden na1ne or aliases?

Yes C:=J No ~Ix_~

If yes, give the reason if any, if none indicate such, and provide the full namc(s) and dute(s) used.

Beginning/Ending Date(s) Used (MM/YY)

Name(s) Reason (If none, indicate such) Specify: First. Middle or Lasl Name

------------·-.. -·- ------

---·-····-·------------

------·-- -·-····-··~--

Note: Dates provided in response to this question may be approxhnate. Parties using this forn1 understand lhat there could be an ovei"lap of dates \.Yhcn transitioning IT-om one na1ne to another.

3. Affiant's Social Security Number:-

4. Government Identification Number if not a U.S. Citizen:

5. Foreign Student ID# (if applicable): ___________ _

6. Date of Bi1th: (MM/DD/YY) -Place ofBirth, City: Glendale State/Province: CA Country: ~

7. Name of Affiant's Spouse (if a'pplicuble) : Gwen Roach

8. List your residences for the last ten (I 0) years starting with your current address, giving:

©2016 National Association of lnsurtince Com111issioncrs 7 Revised 8118/14

FORM 11

(

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Beginning/Ending State/ Dates (MJ11/YY) Address City Province Country Postal Code

Qi(QlioPJ:~ent ·---- Granite Bay CA USA -Nole: Dates provided in response to this question 111ay be approxin1ate, except for cu1Tent address. Parties using this fonn

understand that there could be an overlap of dates when transitioning from one address to another.

Dated and signed this 27'' day of June, 2016 at Sacramento, CA. I hereby certify under penalty of perjury that I am acting on

my ow/~and z-ii~._::~1ents are true and concct to the best of my knowledge and belief.

·----(Signature of A ftiant)

.-" ilt<ltl;_of:_ County of ........... ~~ ---..... ~.-.-The foregomg-in.>!!:ument was acknowledged before me this __ day of _______ , 20 ___ _.J:>y:: _____ _

and: ~ -----~ ------ ~,,,.-/ 'vho is personally kno\Vll to n1e,O'r- __.-__.,--·-who produced the following identification: __ .. ____ .~___..,--

,./~/:,,;;er ..... --~----

~,-·----- ~~ [SEAL~- /// ~tary Pub'.ic _____ _

_ ,.._....-- Printed ~ta~

See Attached Notarization Certificate

©2016 National Association of Insurance Com111issioncrs 8

-------·-~-.....:;;-----

My Cotnmission Expires

Revised 8/18/14 FORM II

ACKNOWLEDGMENT

~---.,,-···-~· ·---~-~

A notary public or other officer cornpleting this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or valid it}:'. of that document.

State of California county of Sacramento

on June 27, 2016 before me, Jana Wesche, Notary Public


personally appeared Kevin Christopher Roach who proved to rne on the basis of satisfactory evidence to be the person(s) whose name(s) ls/aro subscribed to the within instrument and acknowledged to rne that he/she/they executed the sarne in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrurnentthe person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENAL TY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. ,:

'-


(Seal)

(


DISCLOSURE AND AUTHORIZATION CONCERNING BACKGROUND REPORTS (All states except Califor11i11, Mi1111esota 1111d Ok/a/11111111)

This DiS<losure and Authorization is provided to you in connection with pending or future application(s) of The Dentists Insurance Con1pany lcornpany nameJ('~Co1npany") for licensure or a pcnnit to organize ("Application") with a departtnent of insurance in one or more states within the United States, Con1pany desires to procure a consumer or investigative consumer report (or both)("Background Reports") regarding your background for review by a dcpai1ment of insurance in any state where Company pursues an Application during the term of your functioning as, or seeking to t\Jnction as, an officer, 1ncmbcr of the board of directors or other managen1ent representative ("Affiant") of Company or of any business entities affiliated \Vith Co1npany C1Tenn of Affiliation") for which a Background Report is required by a departn1ent of insurance reviewing any Application. Background Reports requested pursuant to your authorization below may contain information bearing on your character, general reputation, personal characteristics, 1node of living and credit standing. ·rhe purpose of such Background Reports will be to evaluate the Application and your background as it pertains thereto. To the extent required by law, the Background Reports procured under this Disclosure and Authorization will be maintained as confidential.

You may obtain copies of any Background Reports about you from the consumer reporting agency ("CRA") that produces them. You may also request 1norc infonnation about the nature and scope of such reports by sub1nilting a wriltcn request to Con1pany. To obtain contact in1bnnation regarding CR/\ or to subn1it a written request tor more infonnation, contact Hu1nan Resources, The Dentists Insurance Company, 1201KStreet,16'" Floor, Sacrmncnto, CA 95819, (800)733-0634 lcompnny's designated person, position, or department, address and phoncj.

Attached for your information is a "Summary of Your Rights Under the Fair Credit Repoiting Act."

AUTHORIZATION: I am currently an Affiant of Company as defined above. I have read and understand the above Disclosure and by 1ny signature below, l consent to the release of Background Reports to a department of insurance in any state \Vhere Co1npany files or intends to file an Application, and to the Cotnpany, fbr purposes of investigating and rcvic\ving such Application and 1ny status as an Affiant. I authorize all third parties.who are asked to provide infonnation concerning me to cooperate fully by providing the requested information lo CRA retained by Compnny for purposes of the foregoing Background Reports, except records that have been erased or expunged in accordance with lavv.

I understand that I 1nay revoke this Authorization at any tin1e by delivering a \vritten revocation to Con1pany and that Company will, in that event, forward such revocation promptly to any CRA that either prepared or is preparing Background Repo1is under this Disclosure and Authorization. This Authorization shall re1nain in t\1ll force and effect until the earller of (i) the expirntion of the Term of Affiliation, (ii) written revocation as described above, or (iii) twelve (12) months following the date of 1ny signature below.

A true copy of this Disclosure and Authorization shall be valid and have the san1c force and effect as the signed original.

K2·vin C ristopher Roach,

// ~ ;/.____ e /-. "

(Signature)

Granite Bay CA USA (Printed Full Name and Residence Address)

6127116 (Date)

Stu~_ County of: __ ..

' fore~ _,_-The foregoing · ~cnt was acknowledged before me this day of ~ ~ , and: -- ____ ___...,,,~~

__ w_h_c_> -is_p_e-rs_o_n_a_ll_y_k_nown to me, or ~ .. - .. -----------

··:><::______ who produced the following identificatj9n;-----~ .... ··:-·~ ·---·~-~"'-~----

---~------_

-20 __ by

[SEAL] _ .... ··

See Attached Notarization Certificate

--~otary Public

Print~1e--------_ -

-------~···· ..... ~

©2016 National Association of Insurance Con1111is::;ioncrs 9

My Co1111nission Expires

Revised 8/ 18/111 FORM 11

ACKNOWLEDGMENT

·y,., notary public or o-iiier officer completing-this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validi.ty of that document.

State of California County of Sacramento

On June 27, 2016 before me, Jana Wesche, Notary Public


personally appeared Kevin Christopher Roach who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENAL TY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. (

~~ :-"~A~scHE. " . ~ ~ R';j'.Ji'A\·. Commission II 2062690 t ~ "'.,'.';).!~Iii.: No1ary Public - Ca11rornla ~ :·: . "-;f%:~~1 Saeramento County _:

.· ··"-""J My Comm. F.xolres Mar 30 2018 ~ '- •-_:,"'V'~/.'''!J''' ~'""'W"~"''l"''W'~11~~~,~~ie

WITNESS my hand and offici!ll seal.

(Seal)

(

I I I l

Jun. 23. 2016 12:41PM No. 3993 P. I

Applicant Company Name : The Dentists Insurance Company NA!C No. 40975 FEIN: 94-2698799

BIOGRAPHJCALjAFFlDA VIT

To the extent permitted by \aw, this affidavit will be kept con!ldcntia.I by the st&te insurance regulatory authority.

(Print or Type)

Full name, address and t•l•phone number of the present or proposed entity under which this biographical sliltement is being required (Do Not Use Gtoup Names).

The Dontjsts Insurance CompJl!l:)'. 1201 K Stt·eet 17~ Floor Sacramento. CA 95814

(800\733-0634

In conne.\tiou with th• above-namoo entity, I herewith make represMliltions und supply infonnation about myself as hereinafter set forth. (Attach addendum or sepnrate •heel If spnce hereon fa insufficle11t to answer any quest/on fully.) IF ANSWER IS "NO" OR "NONE," $0 STATE.

I. 'f>lttr!'M C>

Affiant'sF\lll Name (Initials Not Aoc1:ptabJc): Flrst;_~-~Mii:Ii:Ile: Pi.Itri; S Last RPv f G:tfu


Yo•~ No C=:J b. rue you a citii;on of any other country?

Yes c.J No 00 If yes, what country?--------------

., -3. Affiant's occup•tion orprofossion: f)fw.Tr/r)D'GA"t7$- I

Affiant's business address: fl9:l/ {1.ftj//O S/ P./iff,J /Ji/ 1/,'€.vy. &ft <Jl/t.Jfv

Business telepho,,e: b Q.v-?hr/-bt./oo Business Email: .ie.1.. f@&•-'/[email protected] .c_.,t,,... 4.


Col!ege/Unjversjtv Qjy[fil1Jll1

t1.y/y <.1P 1/ b,m:v.; r ?!;r lftJ f;;; Ill 7

©2016 National Association of lnsunince Commbslonets

Dates Attended (MMJYX}

1kf/11 ·--- t;/Jrt£ Do~roe Obtained

:/35 DogreoObh~

Z>~..D


Jun. 23. 2016 12 41PM

Applicant Company Name:

6. List of memberships in professional societies and .. socladons:

7_

No. 3993 P. 2

NAICNo- --------FEIN:

T elophone Number of SocjewlAssocjatlon

8. List complete employment record for th• past tweocy (20) years, whether oompenseted or otherwise (up to and including present jobs, positions, partnerships, owner of an entlt}', administrator, manager, operator, directorates or officerships). Please list tlte most recent first. Attach additional pag<>• if the space provided i< in&uffitient. It is only necessOI)' to provide telephone numbers and supervisory information for the past ten (l 0) yeors.

~:~:=~~ *mployor'sName: AvJ~@ttvhtkAtt% JJew:ir/BlPit?e Address: J 11 q wk v :zl= City: ti!. t- I) M Sb!tell'rovinco: _Cj.}---'-'-;____----

(

Country: L-($1}= Postal Code: !IJ/J>tdtJPhone: ';1i...i~ffices/Fositions Held: {'? 1Jl71t! 1>ft..,J'SJ.f l'yp• ofBusiness: .P~/t,/,t,./ Supervisor/Contact: 6' lfylA fr ( Beginning/Ending Dates (MM/YY): __ _ ____ Employer's Name: __________________ _

Address: City: State/Province: ---------~ --------- ---------

Country: ----- Postal Code: ---- Pbone: ____ Dffico~IPositions Held: _______ _

Type of Business: Supervisor/Contact: ______________ _

Beginning/Ending Dates (MM/YY): __ _ _ ___ Employor's Name: __________________ _

Address: ___________ City: -------· Sl:llte/l'rovince: ----·

Country: ----- Postal Codo: ____ Pbone: _____ Offices!Positions Held: _______ _

Typo of Business: Supervisor/Co11tact: --------------

Beginnii1g/Endh1g Dates (MMIYY): __ _ _ ___ Employer's Name: __________________ _

Address: ___________ City: _________ State/Province: --------

Country: ____ Postal Code: ____ Phone: ____ Offices/Fositions Held: ______ _

Type of Business:

©2016 National Association ofllisurance Commissioners

Supervi•or/Contact: ______________ _

2 Revised 8/lll/14

FORM II

(

Jun. 23. 2016 12:42PM No. 3993 P. 3

Applicant Company Name : The Dentists lns~co ~pany NAIC No. 40975 :' FEIN: 94-2698799

9. a Have you over been in a posi tlhn wl!i<ti required a fidelity bond?

YesCJ No~

If any claims were made on the bond, give details:------------------

b. Have you evor been denied an indlvidu•I or position sohodul• fidelity bond, or had a bond canceled or revoked?

YesC:J Nop

Jfyes, give detaJls: ___________________________ _

JO. List any professional, occupational and vocation•! licenses (including license& to sell securities) iS&ued by any public or governmental lioeMing agency or regulatory authority or licensing authority that yo\l presently hold or have held in the pruit. For any non-insurance r•gulntory Issuer, idetttlt'y and provide the name, address and telephone number of the licensing authority or regulatory body having )\l!lsdictlon over tho license (s) Issued. If your l>rofessional !icertse number is your Social Security N11mber (SSN) or embeds your SSN or nny sequence of more than five numbers tliat aro reasonably identiflablo as your SSN, then write SSN for that portion of tlie professional lice1'8e number that is represented by your SSN. (For example, "SSN", "12-SSN-345" or "1234-SSN" (lasl 6 digits)). Attach additional pages if the spune provided ls insufficient.

Orgai1izotion1JssuerofLlccnse:1'~t1Y/ '5tff!(I> 14 Address: ~G/ ~·e :/o City:~ Stato/P1·ovlnoo: .Cfj- Co1mtry: (A~t)- Postal Code: q4' (iJ /5 License Type: VMkL !-icense #: d-~ i:ib, B Date Issued (MMIYY): t;b/J:i / Date Expired (MM/YY):«f1¥.=· Reo.son for Termination: ----~------------Non-Insurance Regulatory Phone Number (if known):----------------------

Organization/Issuer of License: __________ Addreso: ----------------

City: ------- State/Province: ------ Countzy: ______ Postal Code: _____ _

License Type:------- License#; -------- Date Issued (MMJYY): ________ _

. .-Date E:tpired (MM/YY): ______ Re..,oo for Termination: ------------------

·]>!on-Insurance Regulatory Phone Number (if known):----------------------

! 1. In responding to the following, {f the record has been sealed or expunged, and the affiant has personally verified that the record was senled or expunged, an nffiant may respond '1no11 to the quct.rti6n. Have you ever:

a. BBen refused an occupational, professional. or vocationa11icense or permit by any regu1atmy authority, or any public administrative, or govtmmenwl licensing agency?

Yes c:::J No ~ b. Had any occupational, professional, or vocational licel1'e or permit you hold or have held, been subject to

any judicial, administrative, regulatory, 01 disciplinory action?

Yes c:J No c)ZJ <t;12Q16 National Association of Insurance Commissioners. 3

Revised $/JS/l 4 FORM 11

Jun. 23. 2016 12:42PM

Applicant Company Name=------------

No. 3993 P. 4

NAJCNo. ---------FEIN:

c. Been placed on probation or had a fine levied against you or your occupational, professional, or vocational license or permit in any judicial, administrative, regulatory, or disciplinary action?

Yos CJ NoQ{::J d. Been charged with, or indicted for, any criminal offense(s) otlm titan civii 1rafficoffenses?

Yes [=:J No ·[25_]

e. Fled guilty, or nolo contemlere, or been convicted of, any criminal offense(>) other than civil traffic offenses?

Yes c:::J No l25:J f. Had .adJudication of guilt witbheld, had a sentence imposed or suspended, had pronouncement of a sentence

suipended, or been pardoned, fined, or placed on probation, for any criminal offense(<) other than civil traffic offenses?

Yll$ C=:J No IBj g, Been subject to a ceili$e and desist lotter or order, or onjoinod, either tempomily or penn~ontly,in atty judiclal,

administrative, regulatory, or disciplinary action, from violating any federal, state Jaw or Jaw of another country rogUlating tbe business of insurance, ••curitie• or banking, or from canying out any particular practice or pr2.Ctices in the course of the 011siness of insurance, securities or banking?

h. Been, within the lost ten (10) years, • parfy to any civil act!on involving dishonesty, breach of trust, or a financial dispute?

Yes c:::J No CS:CJ i. Had a finding made by the Comptroller of any s1ate or the federal Government that you have violated any

provisions of small loan laws, bnnklng or trust company law•, or credit union laws, or lh•t you have violated any rule or re)llllation lawt\llly made by the Comptroller of any state or the Fedora! Government?

Yes c=J No [Z'J j. Had a Hen or foreclosure action filed against you or any entity while you were associated with that entity?

Yes c=J No cx1 If the response to any question above is yes, please provide detalis including dates, locatiom, disposition, etc. Attach a copy oftbe complaint and filed adjudication or settlement as appropriate.

12. List any entity subject to regulation by an insurance regulatory authority that you control directly or indirectly. The tenn "control" (including the terms "controliin~" '~controlled by11 and u\lnder common control with") means the possession, direct or l.ndlrect, of the power to dilect or cause the direction of the managem<>nt and policios of a person, whether through the ownership of voting securities, by contract other than a commercial contract for goods or non-management services, or otl1erwise, unless the power is the result of an official position with or 001porate office held by th• person. Control sh~ll be- prooume~ ·ro exist if any pcrnon, duectly or lndirnot!y, owns, controls,

©2016 N~onal Associat\on oflnsurance Commission= 4 Revi$•d 8/18114

FORM ll

( \

(

Jun. 23. 2016 12:42PM No. 3993 P. 5

Applicant Company Name: The Dentists Insurance Compauy NAIC No. 40975 FEIN: 94-2698799

holds with the power to vow, or \lold• proxi.,. representing, ten percent(! 0%) or more of the voting securities of any otl1er pernon. 1#

"': If any of the stock is pledged or hypothecated iJ1 any way, give details. ______________ _

13. Do [Will} you or ni•mbers of your immediate fl!mlly individually or cumulatively subscribe to or OVlll, beneficially or of record, 10% or more of the outstanding shares of $lock of an:y entity subject to regulation by an imurance Ngulatozy autllorlty, or its affiliates? An "affiliate" of, or person "affiliated" with, a specific person. Is a person that directly, or indirectly through one or more i11tennediarles, controls, or is controlled by, or is under common control with, tile person specified.

Yes C:=J No CX'J If yes, plea.se lderttify the company 01 companies in whicli the cumulative stock holdings represent 10% or more of the oui.tanding voting securities.

If any of the shares of stock are pledged or hypothecoted in an)' way, give details.

14. Have you ever been adjudged s bankrupt?

Yes C::J No c'.25;'.J If yes, provide detlliis: ~---------

15. To your knowledge has any company or entity for which you were an officer or direotN, trustee, investment committee member, key management employee or controlling stockholder, had any of the following events occur while you served in such capacity?

a. Been refused a pannl~ license, or certificare of authority by my regulatory outhority, or governmenrol!icensing agency?

Yes CJ No cgJ b. Had its pennit, license, or certificate of authority suspended, revoked, canceled, non-renewed, or subjeoted

to any judicial, administrative, regulatory, or di$ciplinary action (including rehabilltatioo, liquidation, receivership, conservatorship, federal bunkruptcy proceeding, state insolvency. supervision or auy other similar proceeding)?

Yes C:::J No ~ c. Been placed on probation or had a fin• levie~ against it or against its p•nnit, license, or certificate of

authority lri any civil, critninal, ndmiuistrative) regulatory, or disciplinary action?

Yes c:::=:J No CXJ

©20.16 National Association of Insurance Commiss;oners 5 Revised 8118114

FORM ll

Jun. 23 2016 12:43PM

Applicant Company Nome;-----------

No. 3993 P. 6

NAICNo. --------~ FEIN:

If the answer to ony of the above is yes, please indicate and give details. When responding ro questions (b) and (c), affiant should also include any events within twelve (12) months after his or lier departure from the entity. __

Note: lfrui, affiant has any doubt about the accuracy of an answer, the question should be an.were<! in fl1e positive and an explanation provided

Dated and signed this().?? day of Jv v\L... 20 ~ at AitJ,,J?1J711?'.,,/ W~ I here~y certify under penalty of perjury that J = acting on my own behalf and that the forog¥ng statements are ll'lle an<! correct to tlte best of my knowledge and belief.

_ f~rklntfr -J&if

(

State of: Cf\ County of: s~\-CtdaJ<-" I

The foregoing irtstrument was aoknowledgod before me this ~day of "'O' IM\.L. 2oifL:by B 4-\ '¥ .,,J f4:> l!. \ ~o.M. "ti' -' - (

0 who is penionally known to me, or

~produced tho following identifioation: _ __:<t:.:Pl---'-",,!}'="-'/-=L,_ _____ _

[SEAL]

k··· ~ ' I --K. L DUBAL {

COMM. • lW6993 <> ROTARY PUBLIC>CIJJFORRIA ~

SANTAtLARI COIJllTY MY sommJ<P. f,\oy )1, ~1S I

@2016 Nation a\ Association of lnsuraoce Commissioners 6

My Commis$ion Ex~iros

0~~,\~t<f

Revised 8118114 fORM 11

(

Jun. 23. 2016 12:44PM No. 3993

Applicnnt Company Name : The Dentists Insurance Company NAJC No. 40975 FEIN: 94·2698799

BIOGRAPHICAL AFFIDA VlT Supplemental Pe~sonnl Informntion

(Print or Type)

To the extent pennitted by law, this af'!'idavit w111 be kept oollfident!al by the state insurance regulatory authority.

P. 9

Full name, address, and telephone number of the present or proposed entity under which this biographical statement ls being required (Do Not Use Group Names).

l.

The Dent~ts Insurance Company 1201KStreet17 Floor Sncram~nto, CA 95814

(800)733-0634

Affiant's Ful!Natne {lnitia!s Not Acceptable): Fi!~Ul)}AJ)>Middle:AA//1°) IF ANSWER IS "NONE," SO STATE.

Lost:

2. Have you ever used any other name; including first, middle or last natne, nickname, maiden natne or aliases?

Yesc=J' No~ If yes, give the reason !fall)', if none indic•te such, and provide the full name(s) and date(s) used.

lW!illll!ngffiruling. Datelsl Used fMMIYYl

NM!fill ~n Of none, indicate such) fuii::cifv: Firsl Mjddle or Last N~

Note: Dntos provided In rosponse to this question may be approximate. Pnities using this form understand that there could be an overlap of dates when transitioning from one runne to another.

3. Affiant's Social Security Number:

4. Govenunent Id•ntification Nlll11b•r if not a U.S. Citizen: __________________ _

5.

6. Date of Birth: (h lace of Birth, Ci!)'.:::g.d;f:T'-£e,,._. ___ ~-----State/Province: --1./."1:.:4-Wti&IO\:J-J..:__:.__ Country: U ~

7. Name of Affiant's Spouse (if applicable) :. __ _._M-=4j=...~'l-"'c"-. _"g*"'ov~-"-'l'-'#!h'-""~'\_-=-------~

©2016 National. Assoda'ti.on of Insurance Commissioners 7 Revised 8/18/14

PO~!!!

Jun. 23. 2016 12:44PM No. 3993 P. 8

Applicant Company Name : W k(J1.;, t:hmtD ~1il5 NAICNo. ( FEIN:

8. List your rosidences fotthe last ten (10) years starting with your current addros., giving;

.Boginning!Endlng Dates CMMIYY)

f)()/J!_? 7

Slate/ ~ Province

kMlfi> (Jt~

Note; Dates prov(ded in resporuie to this question may b• approidmate, lll<c•pt for current address. Pai:ties using this form understand that there could be an overlap of dates when transitioning from one addross to another.

Dated and signed this$ day of t /.JI\). . , 20J.fe. of /J{M&'rftr'N l/,'..e...t..J , . J hereby eertify under penalty of perjury that I airt acting on my own behalf and that the forogoing staternO!lts are true and correct to tlle bei;t of my knowledge and belief.

~-\> ' (SfgmitUJ:efi:t;;;

$1ateof; __ ~C~A~--- Countyof fu...\o... ~' The foregoing lnstrument Wllll acl<nowledged before me this :,l.!1 dlly of rJLW0l-. 20Ji!_ by~~ l).<11< \~p.w.:J( and:

0 who is personally known to me, or

~duced the following idontification; _ _,c_=-'l'r:2..._'\'>:.L\"-. ,,,( ~-----

(SEAL]

~@ l . ..

K. L DU!lAL ( COMIU 10l>&993 fl

HOlAAV PUBLIC•CALifORNIA !l; SAttlA CLARA COUlf\'Y J

"!'!Comm. Etp. MAyll,~11

©2016 Narjonal Association of Insurance Commissioners 8

Printed NolllJYName

My CoillllJjssion Expires

05'"''\.9-P l ~

Revisoo 8118114 FORMll

(

Jun. 23 2016 !2:43PM No. 3993 p 7


DISCLOSURE AND AUTHORlZATION CONCERNING BACKGROUND REFORTS (All lilates except Cal(fomia, Mirmesota a11d Oklahoma)

TI1is Disclosure and Authorization ls provided to you in connection with pending or future application(•) of The Dentists Insurance Company [company name]("Compeny") for Uoensure or a permit to organize ("Application") with a department of insurance in one or mot• states wif11in the United Stutes. Company desires to procure a consumer or investigative consuoier report (01 botb)("Background Reports") regarding your background for reviaw by• department of insurBJ\ce in any state where Company pursues an Application during the term of your functioning as, or seeking to function as, an officer, mombor of the boiled of direotors or otl1er management representative r'Affiant") of Company or of any busine.•s entities affiliated with Company r'Term of Affiliation") for which a Bacl<f!r<>und Report is required by a dct>rutuient of Insurance reviewing any Application. Baekground Reports requested pursumrt to your autl1orization below may contain infotil1ation bearing on your character, general reputation, personal characteristics, mode of living 1111d credit standing. The pUf1'0se of such Background Raportll will be to evaluate tho Application and your background as it p~rt•ins thereto. To ti1e extent required by Jaw, tho Background Reports procured under this Disclosure and Authorization will be mointalned as confidential.

You may obtain cop!os of any Background Reports about you from the consumer reporting agency ("CRA") ti1at produces them. You inay also request more information about the nature und scope of such reports by submitting a written request to Company, To obtain oontact informadon reaardlng CRA or to submit a written request for more infom\ation, contnct Human Resources, The D•l\tisls Insurance Company, 1201 K Street, 16'' Floor, Sacramento, CA 95819, (800)733-0634 (company's designated person, position, or department, oddr•s• and phone].

Attached for your information is n "Summlll')' ofYour Rights Under the Foir Credit Reporting Act."

AUTHOlUZATION: I am currently an Affiant of Company es defined above. I have read and underotand ti1e above Disclosure BJ\d by my signature below, I consent to the release of Background Reports to a depru:tmeut of hisuronce in any stat<> where Comp1111y files or intends to file an Applicution, w1d to the Cotnpany, for purposes of investigating and reviewing such Application and my stat1rn as an Afflant. I authorize all third parties who nre asked to provide !nfonnation concerning me to ooopornte fully by providing the requested information to CRA retained by Company for purp-0ses of tho foregoing Background Reports, exoopt records that have been erAAed or expunged in nccordanoiei with Ia.w.

I understand that I may revoke this Authorization at any time by delivering a written revocation to Company and 1hat Ccnipw1y will, in that event, forward such revocation pron1ptly to any CRA that either prepared or is pr•p•ring Background Reporill under this DiscJosuJe and Authorization. This Authorll:Mion shall remain in full force Bild effect u11til il1• earlier of (i) the expiration of the Term of Affiliation, (ii) writt•n revocation as described above, or (Ill) twolve (12) months following the date of my signature below.

A true copy of this Disclosuro end A11thorization shall be valid and have tho s11me force ond effect as the signed original. -

.B e:&rcttvJ !501 \a.A ...... , "I /1.- i-rl tr ~

,M~-='fL~ ' (Signature) (Dato)

State of. Ct\ Collllty of: ~ +o...d~ The foregoing instrument was acknowledged before me this ~ day of 'J~ B-uz..+cr:t,.,q{ Pou./ e.o:..u.. ::I'< ',and:

0 who is persouaily known to me, or

~;reduced the following identlfication: __ c;=4_,_,;_,.D~{~L~. -------

[SEAL]

K. L. OUBAL 1 CO~M. I 206699l "'

NOTARY PURllC>C!UFORHIA !!i SANTA CLAM co um

My Com~, Exp. May II, 2018

©2016 NaltonaJ .o\s~ocia.tion of'Insurancc Commissioners 9

201.f_ by

Rovfaod 8118114 PORM11

( \ ....

(

Applicant Cotnpany Na1nc : The Dentists Insurance Con1pany NAIC No. 40975 FEIN: 94-2698799

BIOGRAPHICAL AFFIDA VJT

'l'o the extent pcrn1ittcd by law, this affidavit ·will be kept confidential by the state insurance regulatory authority.

(Print or Type)

Full na1nc. addrexs and telephone nu1nbcr of the present or proposed entity under which this biographic.ii stalcn1l.!'nt is being 1·equired (Do Not Use Group Names).

The Dentists Insurance Con1panv 1201 K Street. 17'" Floor Suernmento. CA 95814

(800)733-0634

In connection with the above-nan1ed entity, herewith n1ake representutions and supply infonnalion about 1nysclf as hereinafter set fo1ih. (Attach addcndun1 or separate sheet if space hereon is insufficient lo answer any question fully.) IF ANSWER IS "NO" OR "NONE," SO STATE.

1. Affiant's Full Name (Initials Not Acceptable): Fir<!: Dccpinder{Ruehil Middle: ___ _

2. a. Are you a citizen of the Unitc<l St.ales?

Yes c:J[J No C=1 b. Are you a citizen of any other country?

Yes C=1 No ~I 0_~

If yes, \.vhat cou1nry? ~

.1. Aftlant's occupation or profession: Dentist _____________ ··-----------

4. A ffia11t's busi11ess addreos: 1895 Mowry Ave. ff l 04 Fremont. CA 945)8 ___ _

5. Business telephone: 510-794-7058_ Education and training:

c_:ollegc/Universitv lJnivcrsity of Paci lie

Cily/Stalc Stockton, CA

(jraduate Stu<lics College/University llnivcr:;;i1y of Paci tic Arthur A Dugoni School of Den1istry

Business En1ail: _nijjardcntal(~ijg1nail.con1

City/State S:in Frnncisco. ('A

Dates Attended (MM/VY) 0611999-05/200 I

Dates Attended I MM/VY) 0612()01-06/~004

[)egrec Ohlainc_d DDS

()thcr'l'raining: Nan1c C'ity/Statc Dates Attended lMM/YY) GPR Veterans Affairs Palo Alto Medical Center. Palo Alto 07/2004-06/2005

DcgrcclCi.;rtification ()btaincd General Practice Residency

Note: If affiant attended a foreign school, please provide full aLidrcss and ti.!lcphonc nu111bcr of the college/university. l r upplicablc, provide the foreign student Identification Nun1bcr in the space provided in the Biographical Affidavit Supplcn1cntal lnfonnation.

©2016 National Association of Insurance Cornmissioncr:;

Rcvi~cd R1 Ix, 14

FORM 11

Applleitnt Comp•11y Nnmo: NAJCNo. ·---... ---~··-· .. _ FEIN:

!~kn!lilll.~.li'!!Ull.~ ~~Jllllrn1

~o.,1hern Alao10do 40S Uuuldur Ci. l'k-0~1u1<>11.

cCc'"'"°'"c'o','"'"""""'"·"1"y~M,ol,in,"-c>,m01oc' ___ c'c'',~=""'-- ~.::~"""'---

AmotklLn f.lonml 211 H. Ctikag<> Av~ A•ioointi<>n JaniM MoeL"~n-Am~ticn11 Collogo of ~;~;~i~1,:!~ ~~c:,c~"',' --"3'-'12 A~o.~~~?! ___ _ Donli•I•

S1«0TI Pitmon

llnulcv~nl

Onid1crshurg. M"ryhu1d 201[1!__.., __ '.I01.g77.J22l

7. l'r••~nl-Or rrorn•od pn;ilion witl\lhc Applica11l Compony: _ ~{\ It:.kt~+.~

-· ·- ---· ----- -- -------------8. l..iM complo10 mnploy111em rocol\I for 1hc J>ll>! t~nty t2(1) y~or•, wl1<11111r en!OJlllllSfllCd "' oth~rwii;o (ur w aml

tncluJing p1~s~n1 job.!;. p1,.itions, pa~11crllliips, ownor nt' •n cn1i1y, ~dn1[ni~lrolor, manugcr. op•romr, L1ir<cioralci or office1shipo), Ploaso li!l llW mo.'11 rcwo1 f1J>t. Al111ch ~Jdition~l p<l!):l.I~ lf1h1.1 op~co pnrvi<loJ i5 in•iltfieie111. li ii only noccssnry 10 provide 1dcpho110 numbilts and supcrvisury infoml•llon for th-0 J'll'Sl 1on(l0) Y\'U"·

Bcginnlng.'l:n!ling Dme~ (MMIYY): l(l/200$ • prcse1n. 8ni1>l4>Y•r's Narr)I): Nljfar.llill1.!ll...1l.

Typ.:(>fllu!;i1 ..... 'I: Dental Office _______ _ Sul""rviwrlContaot: Dr. Mani1ulcr Nijjar, \JDS-··-

&glrmlug11lndlng D•to•(MMl\'Y):ICll20llS -WIO

Country:USA ·-· - ... - ... P.isl•I Code:'J.13&\

ll<."&innlng.'llndi11i:

Sllpol"l'iS<>r/C<1nlao1:D1.Snun110n Pun

Om cs (MMIYY): (171200~ • prcoooi Empl!>yor', Numo: Artl»r A. l)l.l~oni Uni'' of P"cific Sdmol ofllcnli•lry

Coum1y: USA Poo1~1Cod-0:94103..... __ l'hou~(415)929-6400 Offices/J>osiHtm• lfolt!: C'Lindal ln11ructor

T)11~of[lusinoss: _,, __ Supcrvi!or/Cmita<t:

llogi11nln~r~'.oding UaM{MMI\•\•):

___ ._Cily:

P<>S!•IC:"<>M _Phone:

Applie<1nl Curnp:iny N;m1c: Tlic D<mi!b ln•urnn"" Cu11•p<111)

Sluwrrrovi11ee:

_Ofllccill'osition• Hdd

NAI(: No. 40975 l'BTN; 9,J-lMl~71)lJ

R"i"d ~11~11·1 FORM II

b. lla~t )\>~ cNr boon ,1~111cd "" i1lllivid11~I or ro•lliun ichc<lulc lidcli1y bond, ur lmd a \l<lml <'nnc"<'kLI Lll" Tl!•'<J~od"!

Ill. Li;l oriyprofo~!ional, °'"''P•lim,.1 nnol vocati<>Mt lloen~(lll (inclmlin~ li~n!os m 1011 !«'CUrilio•) i~!U<'d by 11ny publfo or govcn1no:J>tal \ictusil•t agtncy or rcgulu1(>ry •Hlhorily or Hc<Hoing 11u1l1ori1y lh•t you prosc11!1y loold or huw hold ;,, 1ho r;o~l. For any nm1-insmu11cc rugul»lory i'"UCI', i<k11lil)' 111111 rr<wldo Lhc name, n<lrlrc0111nd 1olc1>ho11c uumbcr of 1hc lic""'"'ing Rullinrity orr<'gul•INY bOOy haviugjuriodi'1io11uv-Or1110 liC<>L1Sll (.•) i•iuoxl. lfym1r P'""''""~1nl liccn11< munhe( I~ )'()ur&icM Smui(y N"mbor (SSN}urcmbcd> ymtr SSN <>r a11y l«-'lt~••L<l: 1•rroore 1han fi"c numbu1·; 1h111 ""' rc•Sn1inhly idcn!inabk as ycur SSN, !hon ~·rite SSN for th~• pon1"on oftho proll:••lonol li¢cn~ n~ml>:r 111111 I> rc11rcsc11lcd by you1· SSN. (l·or •x•m11lo, "SSN''. "ll·SSN·.WS'. <>r "'1Zl4-SSN"" (l~~I (, Jiglts)), Altooh ndJlliunol P"B•• ifllw•r"c p1·~vitlod ;, in.umcionc

OtgOniiaLi<lull.<""°' ofl.iccn•c: Do11tttl Board ofCal!f<>tni• A<ldN~s: 2~05 Evergrnen Street, Sulla 1550 City;S~mmenm Srnte1Pro~i11N:Cll Counl1~: USA Pu3!1<\ Codc:9S81~

l.it·cnwT.vrc: DDS. __ Liccnw ":529(13 Dile ls,.iod(MMIYY): Oll/2004

Onie lhpirod {MMIYY):l l/2017 liooson for Tcnnin,,mn:NIA

Ci1y: -----·-- Sl1to/l'rovi11<.><J:

11•10 E~pircd (MMIYY): ... Ren""' for Tonni11a1loo:

1 J. In rcspo11di11g 10 the full,m·ing, iflhc ncor<I hoi bccn •ll"•lcd or C•plmgod, •od 1l1cuniot1! hu• pcrnon•li)" vorilicd 11'01 doc 1w.mt w,. """kd or '1llpnngcJ, "'I 011Tsn1 m.•yt~<pond 'iw" l<l th~qlLCSllun. Havo yuo ~WI'

lk"Oti rol"uSQd nn ooe11pii.1io110L. prufcssi<mul. or ~oen1ion•l liec11'0 ur pc11~l1 by ony r1:uulo1<>ry ou1horiL)'. 01 ""~ publicodminh!!mtiVC, ~f JlCWtnmoni!I lkonsjng 1Lgoncy-/

RWlo<,I M\~tM l'URM II

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Applicunt ('.0111pany Na1ne : ·-- ---·---·----..... -·-···------ NAICNo. FEIN: -------- - -

b, tlad any occupational, profcs:-;ional, or vocational license or pcnnit you hold or have held. been subject to any judicial, administrative, regulatory, or disciplinary action')

Yes [==:J No 1~0-~

c. Been placed on proba1ion or hod a fine levied against you or your occupational, professional. or vocational license or pcrtnh in any judicial. ad1ninistrative. regulatory, or disciplinary action?

Yes [==:J No ~

d. Been chargc<l \Vith, or indicted for, any criTninal offense(s) other than civil traffic offenses?

Yes

c. Pled guilty, or nolo contendcre, or been convicted or. any criininal offcnsc(s) other than civil traffic offenses?

Yes I~-~ No~

r. Had adjudication of gui It withheld, had a sentence imposed or suspended, had pronouncement of a sentence suspended, or been pardoned, fined, or placed on probation, for any crirninal offcnsc(s) other than civil traffic offenses'!

Yes [==:J No [ 0:=J

g. Been subject to a cease and desist lc\'tcr or order. or cnjoincd1 either ten1porarily or pcnnancntly. in uny judicial. ad1ninistrativi.:::, regulatory, or disciplinary action. fron1 violating any federal. state ht\V or laY..' of another country regulating the business of insun111cc, securities or banking, or fron1 carrying out any particular practice or practices iil the course of the business of 1nsuran(;t!, securities or bunking?

Yes [==:J No ~

h. Been. within the last ten (10) years, a party to any civil uclion involving dishonesty, breach of trust, or H

financial dispute?

Yes [==:J No~

1. Had a finding n1adc by the (~ornptrollcr of any state or the Federal C:iovcr111nc11t that you ht1vc viola1cd any provisions of s1nall loan la\.\'S, banking or trust co1npany lU'1-Vs, or credit union laws. or that you have violat!.!d any rule or regulation lawfully 1nadc by tlu.: Co1nplrollcr of' any state or the Pcdcral Govl..'rn1ncn1?

Yes [==:J No ~

J. Had a lien or foreclosure action filed against· you or any entity while you \Vere associated \.vith that entity'!

Yes I,__~ No~

If the response to any question above is yes, please provide details including tlutCs. locutions. disposition, etc. Attach a copy of the con1plaint and filed adjudication or scttle1ncn1 as appropriate.

12. List any cntily subject to regulation by an insurance regulatory authority 1hat you control directly l)r indirectly. The tcnr1 "control" (including the tcnns "controlling," "controlled by" and ··under con1n1on control \Vith") 1ncan:-> the possession. direct or indirect, of the po\\'Cr to dil'cct or cause the direction of the 1nanagcn1cnt and policies or a

Revised 8' \ l'Vl "1

©2016 National Association oflnsurancc Corntnissioncrs FORM 11

---------- --

Applicant Co1npany N1.1111c: The f)cntists Insurance Co1npany NAlC No. 40975 FEIN: 94-2698799

person, whether through the o\vnership of voting sccuritics1 by con1n1ct other than a con1n1crcial contract for goods / or non .. 1nanagcme11t services, or otherwise. unless the power· is the result of an orficial position with or corporuti: < oflice held by the person. Control shall be prcsun1cd to ex.isl if nny person, dircL·tly or indirectly, owns. con!rols, holds with the p<.nvcr to vole, or holds proxies rcp1·cscnting. ten pcrc::cnt (I 0%} or niore of the voting securities of llny other pcrso11 .. ____________________________________ -----

If any of the ~tock is pledged or hypothccated in uny way, give details .. ______________ _

13. Do fWill] you or n1cmbcrs of your in1mcdiatc fatnily individually or cutnulativcly subscribe to or own, bcncfi.cially or of record. 1o~Yc1 or rnore of the outstanding shareR of stock of tiny entity subject to regulation by an insurance regulatory authority, or 'its affiliates? An "afliliatc~' ot: or person "affiliated" \vi th, a Mpecific person, is a person that directly, or indirectly through one or more iillcnne<li~trics, controls, or is controlled by, -or is under common control \-Vith, the person spccific<l.

14.

Yes [--] No [}CJ

If yes, please identify the company or cotnpanlcs in which Lhe cun1ulutivc stock holdings represent 1 O'Y.1 or 1norc of the outstanding voting securities.

If any of the shares of stock arc pledged or hypothccatcd in a11y way. give• dcll1ils.

Have you ever been adjudged n bankrupt'?

Ycsl ~ --~ No [}CJ

If yes, provide details: __ , __ ,, __________ _

15. To your know-ledge has any <:01npuny or entity for \Vhich you \¥ere an of'ficcr or director, tn1stl!C, invi.:stn1cnt con11nitte~ men1ber, key 111anngc1nc11l ctnployce or controlling stockholder, had any of the IOlto\ving events occur \-Vhile you served in such capacity?

a. Been rcllisc<l a pCn11il, license, or ccrtifil'l.l1L' of authority by any regulntory nuthority, or govcrnn1c111al· licensing ugcncy?

Yes ,_I _ __, No ~j lil_~

b. Had its pcnnit. license, or certificute of authority Sll8pcndcd, revoked, canceled, 11011-rcnc\\·cd, or subjcch:d tn any judicial, ad.n1inistn1tivc, rcgu!utory, or iliscip'linary 11ction (including rchabHitatlon. liquidntion_, receivcrsl1ip. conscrvntorship, federal bankruptcy proceeding, state insolvency·, supervision or any other sirnilnr proceeding)'!

C, Been placed on probation or had a fine levied against it or against i1s pcnnit. li('l'llSl'. or ccrlilicatc of authority in any civil, crhninal. adn1inis1rativc, regulatory. or di!->ciplinary nction?

Yes c=J No [gcj

(D2016 National Association of Jnsurance Con1111issioners 5 Revised ti/! Ht 14

FORM II

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Applicant Company Name: ____________ _ NAIC No. _____ _ FEIN:

If the answer to any of the above is yes, please indicate and give details. When responding to questions (b) and (e). ufliant :should also include any evcnts·\vithin tv..-elve (12) nlonths al\er his or her departure frorn the entity.

--------------- ----- ·--···- -----·- ·-- -

Nole: !fan affiant has any doubt about the accuracy ofnn ans\l/Cr, the question should be ansv.1ered in the positive an<.1 an explanation provided,

Dated and signed this liJl day or ___ J\\._(\_t _ . 20 J_f1_ nt __ ·1f1.NY\..2f:!"_ _ --~· I hereby certify under penalty of pc(jury that I lun ucting on 1ny O\Vl1 behalf and that the foregoing stalen1ents are true and correct to the best of my knowledge and belief'.

County of: .f1Lf±M @.8 The foregoing instrument was acknowledged before me this :;'~g__duy of-3" <..l"'°' r,-: _ .• 20 J.C_ by :~_j)££'._J<:,,__J4;; oI /-)and:

who is personally kno\Vll to tnc, or

who produced the following identiflcution: ___ _ D.·L·

[SEALI SUKHVEER KAUR GILL COMM. #2109821 "

Nolory Public . Calltornla ~ Alameda County ~

Comm. Ex Ires 2, 2019

1')2016 National Association nf I nsurancc Con11nissioners Rc\'iscd ~1 l 8/ l <l

FORM II


BIOGRAPHICAL AFllfDAVff Supple1nentul Pet'sonul Infom1utio11

(Print or Typ~l

To the extent pcnnitlcd by law, this a fficlavit will be kept confidential by the state insurance regulaillry authority.

Full 11a111e, uddre:-;:-;, and 1elcphonc number of lhc present or proposed entity under which this biographical slutc1ncnt is being required (Do Not Use Group Names).

I.

The Dcntisls 1 nsu1·011cc ConlU1!.llY 120 I K Street, 17'" Floor Sacrumento, CA 95 814

(800)733-0634

Affianl's Full Name (Initials Not Acceptable): First:Deepinder ___ Middle: _____ _ IF ANSWER IS "NONE," SO STATE.

LaslSahotu

2. Have you ever use<l any other narnc. including first, tniddle or last nan1e, 11ickna1nc1 n1aidcn name or aliascR?

Yes~ No C:=J If yes. give the reason ifnny1 if none indicate such, und provide the 1l1ll nan1c(s) and dutc(s) used.

Bs~i nni ngl['~nding Date(sl.!J~cd fMM/YYl

NamcM Reason (1[ none. indicate such}_ Specify: First. Middle-or Last Name

Birth - August 2009 __ _

---···--·--·--·····------

--·------~-----

____ ,, ______ _

----··----

--------------

Not!.:: f)alcs provided in response to this question tnuy be npproxhnate. Partict1 u!'iing this fonn undcrstnnd t.hu1 ·there could be an overlap of dates \Vhcn transitioning fron1 one ru1n1c lo another.

3. Afftant':; Sociu\ Security Nun1bcr_, _______ _

4. Govcmmcnt lclcntiftc11tion Numbel' if not a U.S. Citizen: NIA -----------5. Foreign Student IDll (ifapplicnblc) :NIA ____ _

6. Date of Birth: (M M/DD/YY) : ____ Place of Birth, City: Sacrnn1enlo --............ -------··---

State/Province:CA ---·----- Country: USA __ ··-··---···-·--··---·-·-·- --· ···--··-·--···- ..

7. Name of Afliant's Spouse (if applicable): Avnect Sahota __ -----·-·---··" -·------·---·

8. List your 1~sitlc•11ccs for the last ten ( 10) years starting with your current address, giving:

l0201 (i Nalional Asso.cfolion of ln:;urance Con11nis.<;loncr." 7 Rcvi~cd 8/J 8/l 4

FOllM 11

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Applicant Con1pany Nan1e :

Bcginning/En<ling Dntes IMM/YYl

0712005-08/2009

08/2009.

12120 I 0 present

State/ Province

Fremon!, CA USA•----·-

NAIC No. FEIN:

Fremont, CA-~--___ _

Country Postal Code

Note: Dates provided in response to this question 1nuy be approxiinatc, cxccpl. for current addre~s. Purtics using this forn1 understand that there could be an overlap of dates when transitioning fro1n one address to another.

Dated nnd signed this ·-~Q_ dny of ... ..11)Y\~- ·-·' 20_j_\q. nt __fr.t.nt~ _______ . I hereby ccnify under penalty of perjury that I arn acting on my O\Vtl bchalfnnd lhat the foregoing slatcn1cnts arc true and correct to the best of my know led ca belief.

'~-- - _-!) '. (S -A-t'ffant)

State of: (_ AL l fQ t--cJ Ip,

The foregoing instrument was acknowledged before me this'.1,g dny of 'j\),l'J(~'

and:

who is personally kno\Vl1 to n1c, or

\VhO produced the roJlo\Ving identification: ,. __ _

. 20Jl,_ by J)..£fP I f'-l))t-)2... /~-f !Jho7 I)

[SEAL] SUKllVEER KAUR Gill COMM. #2109821 z

Notary Public • California ~

Notary Public . s cJ Y> ! \) [CE'2- '£/) u l'c.. .01~c,_ Printed Notary Na1ne Alameda county ~

Comm. Ex Ire$ Ma 2, 2019

©2016 National Association of Insurance Con1missioner:>

/Yl A-!(~_2,.;J 'J- ----My C.'01nn1ission Expires

Rcvis.~d r.;11X!14 FORM 11

Applicant Company Name: The Dentists Insurance Co111pany NAIC No. 40975 r-EIN: 94-2698799

DISCLOSURE AND AUTHORIZATION CONCERNING BACKGROUND REPORTS (All stales except Cal!(<mtia, Mi111ie.w1ta and Okfalwma)

This Disclosure and Authorization is provided to you in connection \Vit:h pending or future applh:at.ion(s) of ·rhc Dentists Insurance Co1nruny [con1pany n1une}("Con1pnny~') fo.r liccnsure or a pern1it to organize (11 Application•·i) \Vith a dcpu11n1cnl of in8un1nce in one or 1nore states within the Lrnitc<l States. Co1npany desires to procure a consutncr or invc8tigativc consumer report (or both)("Background Reports") regarding your background for review by a dcpart111c1'1 of insurance iii 11ny state \Vherc Cornpany pursues an Application during t11c 1cnn of your-runctioning as.1 or seeking to function as_. un otT;ccr, n1i:.~n1bcr of the board of directors or otllcr 1111:1nagcrncnt representative ('~Affiant") of Con1pany or of any business entities aflili111ed wilh Company ("Term of Aflilialion") for whicl1 a Background Report is required by a ·dep1u1ment of insunincc reviewing any Application. Background Reports requested pun:uunt to your authorization bclo\v n1ny contain inforrnntion bearing on your character. general reputation. pcrso-nul charnctcristics, tnodc of living and credit standing. The -purpose of such Buckground Reports will bo to e:vaiuatc the Application and your bi!ckground us it pcrt~1ins thereto. To the extent required by law, lhe Background Reports procured under this Disclosure nnd Aulhorization will be mainlained as confidential,

You rnay obtain copies of 1:1ny Background Reports about you fr_on1 the consun1cr reporting age11cy (-"CRA") lhnL produces thc1n. You 1nay also request n1orc infonnat:ion about the nnture and scope of such reports by sub111itting a \vrittcn request to c:o1np:iny. To obh1in contact infonnalion rcgurding CRA or to subn1it a written request for 1norc infonnation,.contact Hurn.an Resources, The Dentists Insurance Company, 1201KSl!'Cet,16'" Floor, Suerumcnlo, CA 95819, (800)733-0634 \company's designated l'crson, posit.ion, or de1utrtnu.~nt~ address and phone].

Al1ached tor your infonnatio11 is a "Summary of Your Rights Under the Fair Credit Reporting Act."

AU'J'1'JORIZATION: I am currently an Affi:int of Cotnpany as defined above. I have read and understand the above Disclosure and by 111y signature bclo\v, I cons~nt to the release of Background Reports to a dcpar11ncnt of i.nHurnncc in any stntc \Vhere Co1npnny files 01· intends to file an Applicatlon, ilnd lo the Con1pany-, for purpose~ ·Of investigating und reviewing such Application and n1y status as an Affiant. I authorize all third parties \Vho are asked .to provide information concc111ing me lo cooperate fully by providing the requested i11fo1mation to CRA relnincd by Company for pu~'OSCS or the foregoing Background Reports, except records thal have been erased or expunged in accordance with hl\.V.

I unders1and thul I 1n-uy revoke this Authorization al any tiine by delivering a \vritlcn revocation lo Co1npany and t11at Company will. in that event, tOrward such revocation pro1nptly to uny ('RA th11t oithcr prcpnrcd or is preparing Background Reports under this Disclosure and A11thorizn1ion. This Authorization shall remain in full Force and cfl'ccl until the earlier of (i) the expiralion of lhe Tc1111 of Affiliation, (ii) wrillcn revoclltion '" described a bow, or (iii) twelve ( 12) months following the date of111y signilturc below.

A true copy of this Disclosure and Au1horization shall be valid an{I have the sa1nc f'orcc and elTcct as t.he signet\ original.

Dcepinder Snhola Fremont, CA------··-----·-· ·--··--··--···-·-·-

--·- __ ----···----~~ (P~led l'ull Name and Residence /\ddrc.<s) ---- (> / ?>_D / J_fi.. __ (~~- (Date)

The foregoing instrument was acknow\erlged before me >his 3,_<;:_ <illy of 'J,_UiV'\::_ __ , 20._.j_,_ by

J)12G:J?_11.,iJ2Eg~CJilJ1c17 A , and:

v.1ho is personally known to n1c1 or

who produced the following idcntilication: ______ j}J;_. _____ _

[SEAL] SUKHVEER KAUR Gill

©2016 Nntionnl Association or lnsuruncc Con11nissioncn; 9

RcvJ:.;cd H/1 H.114 FORM l l

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Aprlica.111 Con11~~11y NanH.': The Den1ists lnsur:11wc Coinpany

FEIN:

DISCLOSURE AND AUTHORIZATION CONCERNING BACKGROUND REPORTS

. · · (California) . .. , . I.I. I). "I I ' l ' · · · · · · · 1· · f 'I'll<' J)c1111st'i lnswt1nt:t l1~ 1~<: osun: aJH l\Ul 1onz.a11on is pro\·1<lcd to vou 111 (.:nnncclmn w1th a ri.:n<ling app 1cat1on tJ .• · ·• (. · I , · " · · . . - . · · ") 'tll a dcparirncnt nf ,nn1pa11y co1npuny n1unt•/("l.nrnpm1v") lor hc<:11sun: or a pcrmn to orgunizc ( .. Applti.:ation \Vl in~unmcc in one or n1nrc states \~·ithin l11e Oni,11.xl States. Co1nranv dc:->irc-s rr~ proc-ure a con.su1ncr or investigative con::;urner n;port (Or both)("Hackground Reports") f-c·ganling yr1ur h:1ckgroun:i for rt.'viC\\" by an~· dcpartJnent of insurancc_ ln s~ch stat.c~ 'vhcrc Cmnpany is ..:urrc.:-1nly pursuing an Applil'Htion. because you are either fl.1nc1inning as. or arc scckinf! to ltn1cllon a_s. dn 1.ltl\ccr. member n/' the ho;ird {~f directors ur other rnanagcrnent rcpn.!sentativt! ("Al1iant'') nf Co1npfU1)' <1r or m1y busine:-.:;_ cntitic11 3ff\liaLCd \~'ith Cotnpany (''Tenn of Aflilintion .. ) for \Yhich a Backgrot1nU R~JX'rl is requlrcd by a dcpartn1cnl of insurnnce reviewing any Application. Background Ri.!ports will~ ohtuincd through ()\~·ens ()nlin~, Inc., 3802 Ehrlich Roud, Suite 307, Tan1pa Florida 33624 jnarue of C'UA, addrcssj("'CRA"). Background Rcpurts requested pur:;uant !\') your au1horira1ion bdo\\" rnuy contain inf0rnuHi0n bearing (,.)11 your i::buractcr. genera! reputation. personal charactcri.:;tics. rnode of living and i:::rcdi1 standing. TlH? purpose ofsu.,;h Background RCJ'l'.')ftS will he to cvnlu.:1le lh~ Aprlkation an<l ynur backgrounJ as it f'll"l1llin5 thcrC'lo. To the cxt.:nt required by luw. t.hc UackgrtiunJ Rl·ports procurcJ under lhis J)i::;closurc and 1\uthorizati<Jn \Vill be maintained a,c; co11ftde11tial. You 1nay rcyuc~1 rnon:: infonnati(ln about the: nature and S(.'Opc of Background Reports produccJ by any consun1cr reporting agency ("CRA ") by subrnittinµ u \''ritlcn rcquc:st to Company. Y(HI ·should suhniit uny :such \\Tittcn n:qucst for 1nore inJ()m)::Hion, to Jhnnan Rcsnurccs, J""h~ Dentists lns11rancc Cornpany. 1201 K Slrtcl, Sacran1cnh1. CA 95814 {800)733-0634 lcnrup;iny's designated person, position, or departn1cnt, uddress nnd phonej.

1\ttu.cbed for your infrnn1::ition i:i 11 "'Sll1nn1U1J' of Yow· Rights Undt."r the F<:iir CrcJi1 Reporting Act." You \\'ill be provided 'vi th a copy oft1ny BackgjPund Report prot:ured by C\~rnr[uty if you check !he box bclo\v,

ts/ By cht!cking this hox, I rcq1Jcsl a copy o!' any Background Rerx,rt fr0rn any CR.-\ retuincd by

Cornpuny, at no extra charge. 1. ndcr section 1786.22 uf' the Cu!ifon1iu Civil Cod~, you 1n:1y \'iew tbi.: file rnuinluinl,.'J on you by the CRA listt•d alxive. You 111ay ulo,;o obtain a copy of this file, ur.:~n ~11hmit1lng pr'1pcr id~ntific<1!io11 and puying ihe cosls uf duplication ~crviccs. hy ;1pp1..·<t.ring al lbc CRA in person or hy nm.ii: ynu may al!:io n .. ·ccivi: ;.i ~tinHnary oJ' the fili.: by telephone. The CRJ\ i" r!!quircd to htivc personnel available to cxpluin your tile to you and tbc CRA inust l':-:rlain tu yuu any Cl'dl..'d inlhn1nllil1n uppcarin)l in )'OUr file. ff )'OU appt:llf in perc,on. )'Ull IH:1.\ be acc,1n1paniL'"d hy llliC \)\her per~{lll Of your L'll1'll'-:illg, p1uviJ...:J thal pl!l'SOll

furnishes pnipcr idi.-:n1ificJtion.

AtJT11C)Rf ZATI ()N: J a1n ct11Tently an A rfirn1l of Cninrany as Jc tined ah11vi::. I h~J\"L' read und undcht:tnd the ah11\ i.:

Disclosure and hy rny signature belo\~', J consl'lll lo the release nf Bat:k~rnunJ R;.·11,1rt:-. to a ~h:-pur1t1h~11t of insurance in :1ny :.tate \\·here Co111pany files or intends to lilt· an Application, a·nd ~o the Cornpan:-·. t'nr ptlrJ1ll~t's of in\·c~ti~~1tinµ anti ri.:v)c\ving such Applicaiion wid n1y s1atus a:-; an 1\fliant. ! au1hnri;c ull 1hird pw·1ics \\Ii<> <!fl.! u:>ked 111 rrn,·idc infr1nnallon 1.:on(JC'rning n1c to cooperate fully by pn1viding the: rcqucsti.:J ink•nn.ilion lo CRA rctninL'd by Co111pan:- t'nr purp01:>0~ of thl.' 1bn.:g,'1ing. Back~:.round Rcpt'Jrls, except r~~ClJnh; lhal have hccn c-n1scU or expunged in ;_u::i.:onl1ni.:i: \Villi la\\',

1 understand th<it I 1n~iy rt'v»ke this :\ulhorii'~tlion lli any tirnc by delivl..'rinp a \\Tilll·n rc,·o.;_·ati<~n t<1 Con1pany and that Company will, in thal event, fon\'ard SlH..'h rcvo(.·.ution rrompLly to nny CRA thal (.·ithi.:r prepared i.•r is preparing Background Ri:p1,)r1s u1H.kr this Disclosure and Authoriz<1tinn. 111 nn i..'Vcn!, howt.:Vl'r. ,,·ill this aulllllri1.;:1inn rc1nuin in effect bcy0nl\ \\\"cl\·c { J 2) rnunths follo\\'ing the date of 1ny signature bclO\i'.

A true cory ofthls Disclosure and Authori1~i1ion shall be \·uliJ and ha\·i: thi: saint.: l\..,rce and c!Tl•ct as the signed original.

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"""' of, C t·\<,j (::0_;' jV /fl· County of .• fl:-<-J:i.M t'l) A ~olt, \XE'f 11.Ji)T e.. ki}ut.-. S'1111074

TI1c fon~going lu<>tnunenl '''II" 1wknowlcdp,cd bel't,rc me this Jr~ day of .. Jl .. ~us:±~---·· 20 by -.. ~.-... -- .. --.--.......... _ _,and:

who is per.ui-tmlly known to tnc, or

who pmdoced the following idcntilic~n:

~------=-~~~ "\ !SFALl Notoij Public

Printed Notary Nnim: .s:'01c vivFE',L K G Ill.

My Co11unission Expil'l:s C>') / ?- ) 2c 1\ Revised 8118114

' 02016 Nntitiual Associa1io11 o!'ln<;urunce Com1nls~l(1m .. 'f'S FORM !I

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northwest dentists insurance company acquisition by the ... · from parkside dental 1.951.688.4744...

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