Section Ins 6.52 - Biographical data relating to company officers and directors(1) PURPOSE. This rule is intended to implement and interpret ss. 611.13(2), 611.54(1) (a), 611.57, 618.11(4) and 618.21(1) (b), Stats., for the purpose of setting standards for the reporting of biographical data relating to company officers, directors, promoters and incorporators, or other persons similarly situated.(2) SCOPE. This rule shall apply to all persons proposing to form an insurer under the laws of this state and to all nondomestic insurers applying for admission to this state and to all insurers authorized to do business in this state except as follows: (b) Domestic fraternal benefit societies.(c) Nonprofit service plans, cooperative sickness care plans organized or operating under ss. 185.981 to 185.985, Stats., voluntary benefit plans organized or operating under s. 185.991, 1977 Stats., and motor club service companies organized or operating under ss. 616.71 to 616.74 and 616.76 to 616.82, Stats., and donor annuity societies.(3) REPORT OF ORGANIZATION OF A DOMESTIC INSURER OR ADMISSION OF A NONDOMESTIC INSURER. Biographical information in form and substance substantially in accordance with Form A, shown at the end of this rule, shall be furnished to the commissioner of insurance by all promoters, incorporators, directors, trustees and principal officers or proposed directors and principal officers, as the case may be, of an insurer being organized or of an insurer applying for admission. Financial and character reports of any such persons may be ordered by the commissioner and the cost or expense of such reports shall be paid by the incorporators as an organization expense or by the insurer applying for admission.(4) DEFINITION. The term "officer" as used in this rule shall include the president, one or more vice presidents, secretary, treasurer, chief actuary, general counsel, comptroller and any person, however described, who enjoys in fact the executive authority of any such officers.(5) REPORTING WITH RESPECT TO NEW OFFICERS AND DIRECTORS SUBSEQUENT TO ORGANIZATION OR ADMISSION. A report shall be provided by each domestic insurer to which this rule applies with respect to the appointment or election of any new director, trustee or officer elected or appointed within 15 days after such appointment or election. Such report shall be prepared by the company in form and substance substantially in accordance with Form A, shown at the end of this rule.(6) SUBSEQUENT REPORTS. When such a report has been provided to the commissioner by a company in accordance with subs. (3) and (5) of this rule, no further report concerning subsequent changes in his or her status as an officer or director of such company need be reported to the commissioner provided, however, the company shall promptly report to the commissioner any information concerning the conviction of an officer or director for a felony or the naming of a director, trustee or officer, other than as a party plaintiff or complainant, in any criminal action or in a civil action in which fraud was an issue.(7) ADDITIONAL INFORMATION. The commissioner may request from any company such additional information with respect to any of its officers or directors as he or she may deem necessary and such request shall be promptly complied with by the company to which such request is directed. FORM A
STATEMENT OF EDUCATION, PRIOR OCCUPATION, BUSINESS EXPERIENCE AND SUPPLEMENTARY INFORMATION
STATE OF: ss:
COUNTY OF:
The undersigned, being first duly sworn upon oath deposes and says:
1. The affiant's full name is (initials not acceptable):2. The affiant's official title and principal duties with the insurance company is or will be:3. The affiant's business address is: Telephone: __________
4. The affiant's residence address is: TELEPHONE: __________
5. The affiant's age is: Sex
Birth place
Birth date Social Security No.
6. The affiant was never known by any other name(s) other than that shown above, except as follows (state such other name(s), when used, reason for change, and date of adoption of present name):7. The affiant will subscribe to or owns, beneficially or of record the following amount of shares of stock of the insurance company and the consideration given for same:8. The affiant states that his or her capital investment in the insurance company was not obtained from borrowed funds, except as follows:9. The nature and tenure of each occupation or employment of the affiant for the last ten years prior to the date of this statement is as follows (present a continuous schedule, including time spent at educational institutions, and period of employment) Beginning Date | Name and Address of Employer or School | Business Capacity or Title | Termination Date | Reasons for Termination |
10. The affiant's educational history is as follows (include all schools attended of the college or graduate level) Name and Address of Institution | Course | Attendance No. Years/ Dates | Degree Received | Date of Degree |
11. The affiant has never been convicted of a felony, except as follows:12. The affiant has never been named in a criminal or civil action in which fraud was an issue, except as follows:13. The affiant is not an officer or director and has no other relationship with any other insurer which has the effect of lessening competition substantially or in which such insurers have material adverse interests except as follows: (Signature of Affiant)
Subscribed and sworn before me,
a Notary Public, this day of, 2,
Notary Public
(SEAL)
My commission expires:
Wis. Admin. Code Office of the Commissioner of Insurance Ins 6.52
Cr. Register, June, 1973, No. 210, eff. 7-1-73; emerg. r. (2) (a), eff. 6-22-76; r. (2) (a), Register, September, 1976, No. 249, eff. 10-1-76; am. (2) (c), Register, March, 1979, No. 279, eff. 4-1-79; am. (5), Register, March, 1981, No. 303, eff. 4-1-81.Amended by, CR 17-015: am. (5), r. Form B Register December 2017 No. 744, eff. 1/1/2018