Form FIS0361 "Affiliate Statement" - Michigan

What Is Form FIS0361?

This is a legal form that was released by the Michigan Department of Insurance and Financial Services - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2015;
  • The latest edition provided by the Michigan Department of Insurance and Financial Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form FIS0361 by clicking the link below or browse more documents and templates provided by the Michigan Department of Insurance and Financial Services.

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Download Form FIS0361 "Affiliate Statement" - Michigan

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FIS 0361 (5/15) Department of Insurance and Financial Services Page 1 of 1
This form is intended for use by
Affiliate Statement
Purchasing Groups and Risk Retention Groups
Name of Applicant / Registrant
Tax ID Number (FEIN)
Check each box that below that describes your relationship to the applicant/registrant. Enter all requested information.
Each of the persons or entities shown below is required to complete this statement. Corporate stockholders enter primary mailing and business addresses for the corporation.
Owner, Officer*, Director, Partner or Member (Limited Liability Companies)
If affiliated party is a Corporate Stockholder, complete this section:
Individual Stockholder of 10% or more of the stock
OR
Corporate Stockholder of 10% or more of the stock
Name of Corporation
*Officers include, but are not limited to, Chief Executive Officer (CEO), Chief Operating Officer
(COO), Chief Financial Officer (CFO), President, Vice President, Secretary, Treasurer
Your Name and Title as it relates to the Applicant/Registrant Group
State of Incorporation
Percentage of Ownership of Applicant/Registrant Group
%
Your Social Security Number
Corporation Tax ID Number (FEIN)
MAILING ADDRESS
BUSINESS ADDRESS or check here  if same as Mailing Address
Street Address
Floor or Suite Number
Street Address
Floor or Suite Number
PO Box Number
PO Box Number
City
State
ZIP Code
City
State
ZIP Code
Please answer all questions completely. If you are completing this form on behalf of a corporate stockholder or other business entity, answer on behalf of the corporation, not on
behalf of you as an individual. If additional space is needed, please clearly identify each response by question number and attach the continuation(s) to this statement. Enter your
name and Social Security Number or parent company’s name and FEIN in the upper right corner of each attachment. Attachments become part of this statement.
1. Have you or the applicant’s corporate stockholder (if applicable) ever been refused a license, or has any action ever been taken against any professional license held by
you? An action can include, but is not limited to: Suspension, revocation, denial, limitation for cause, disciplinary action, fines, etc.
If yes, please identify the type of license, licensing state, license number, and an explanation of the action taken.
 Yes
 No
2. Have you or the applicant’s corporate stockholder (if applicable) ever been convicted of a felony or any misdemeanor other than minor traffic violations?
If yes, please explain, including dates and final disposition.
 Yes
 No
3. Have you or the applicant’s corporate stockholder (if applicable) ever been subjected to any credit or financial proceeding necessitating court intervention?
If yes, please explain. Attach a copy of the complaint, final court judgment or order, or other disposition.
 Yes
 No
4. Are you currently licensed as an insurance producer in any state?
If yes, please indicate all the states in which you currently hold an insurance producer license.
 Yes
 No
I certify under penalties of perjury that the information above and attached is true, accurate, and complete.
Signer’s Name and Title (typed or printed)
Signature
Date signed
PA 218 of 1956 as amended requires submission of this form by each person or entity described on this form. Failure to complete or submit this form, misrepresentation, omission of
material fact or fraud in this statement may result in a denial or revocation of authority to do business, fines, and other compliance actions.
When complete, submit with application form to:
Department of Insurance and Financial Services
PO Box 30165
Lansing, MI 48909-7665
FIS 0361 (5/15) Department of Insurance and Financial Services Page 1 of 1
This form is intended for use by
Affiliate Statement
Purchasing Groups and Risk Retention Groups
Name of Applicant / Registrant
Tax ID Number (FEIN)
Check each box that below that describes your relationship to the applicant/registrant. Enter all requested information.
Each of the persons or entities shown below is required to complete this statement. Corporate stockholders enter primary mailing and business addresses for the corporation.
Owner, Officer*, Director, Partner or Member (Limited Liability Companies)
If affiliated party is a Corporate Stockholder, complete this section:
Individual Stockholder of 10% or more of the stock
OR
Corporate Stockholder of 10% or more of the stock
Name of Corporation
*Officers include, but are not limited to, Chief Executive Officer (CEO), Chief Operating Officer
(COO), Chief Financial Officer (CFO), President, Vice President, Secretary, Treasurer
Your Name and Title as it relates to the Applicant/Registrant Group
State of Incorporation
Percentage of Ownership of Applicant/Registrant Group
%
Your Social Security Number
Corporation Tax ID Number (FEIN)
MAILING ADDRESS
BUSINESS ADDRESS or check here  if same as Mailing Address
Street Address
Floor or Suite Number
Street Address
Floor or Suite Number
PO Box Number
PO Box Number
City
State
ZIP Code
City
State
ZIP Code
Please answer all questions completely. If you are completing this form on behalf of a corporate stockholder or other business entity, answer on behalf of the corporation, not on
behalf of you as an individual. If additional space is needed, please clearly identify each response by question number and attach the continuation(s) to this statement. Enter your
name and Social Security Number or parent company’s name and FEIN in the upper right corner of each attachment. Attachments become part of this statement.
1. Have you or the applicant’s corporate stockholder (if applicable) ever been refused a license, or has any action ever been taken against any professional license held by
you? An action can include, but is not limited to: Suspension, revocation, denial, limitation for cause, disciplinary action, fines, etc.
If yes, please identify the type of license, licensing state, license number, and an explanation of the action taken.
 Yes
 No
2. Have you or the applicant’s corporate stockholder (if applicable) ever been convicted of a felony or any misdemeanor other than minor traffic violations?
If yes, please explain, including dates and final disposition.
 Yes
 No
3. Have you or the applicant’s corporate stockholder (if applicable) ever been subjected to any credit or financial proceeding necessitating court intervention?
If yes, please explain. Attach a copy of the complaint, final court judgment or order, or other disposition.
 Yes
 No
4. Are you currently licensed as an insurance producer in any state?
If yes, please indicate all the states in which you currently hold an insurance producer license.
 Yes
 No
I certify under penalties of perjury that the information above and attached is true, accurate, and complete.
Signer’s Name and Title (typed or printed)
Signature
Date signed
PA 218 of 1956 as amended requires submission of this form by each person or entity described on this form. Failure to complete or submit this form, misrepresentation, omission of
material fact or fraud in this statement may result in a denial or revocation of authority to do business, fines, and other compliance actions.
When complete, submit with application form to:
Department of Insurance and Financial Services
PO Box 30165
Lansing, MI 48909-7665