3. The affiant’s business address is:
      Telephone: __________

4. The affiant’s residence address is:
      Telephone: __________

5. The affiant’s age is:  
  Sex  
  Birthplace    
  Birthdate   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):

- See PDF for table

10. The affiant’s educational history is as follows (include all schools attended of the college or graduate level):

- See PDF for table

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:      

Ins 6.52 History History: 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; CR 17-015: am. (5), r. Form B Register December 2017 No. 744, eff. 1-1-18.

Ins 6.54 Ins 6.54 Prohibited classification of risks for rating purposes.

Ins 6.54(1) (1) Purpose. This rule interprets and implements ss. 601.01 (2), 625.02, 625.11, 625.12 (2), 625.13, and 625.21 (2), Stats., and ch. 628, Stats., for the purpose of prohibiting certain practices.

Ins 6.54(2) (2) Scope. This rule applies to all contracts issued, renewed or amended in Wisconsin affording automobile insurance coverage and all contracts issued, renewed or amended in Wisconsin affording coverage for loss or damage to real property used for residential purposes for not more than 4 living units or affording coverage for loss or damage to personal property used for residential purposes.

Ins 6.54(3) (3) Prohibited practices.

Ins 6.54(3)(a) (a) No insurance company shall refuse, cancel or deny insurance coverage to a class of risks solely on the basis of any of the following factors (taken individually or in combination), nor shall it place a risk in a rating classification on the basis of any of the following factors without credible information supporting such a classification and demonstrating that it equitably reflects differences in past or expected losses and expenses and unless such information is filed in accordance with ss. 625.12, 625.13 and 625.21 (2), Stats.:

Ins 6.54(3)(a)1. 1. The applicant’s or insured’s past criminal record;

Ins 6.54(3)(a)2. 2. The applicant’s or insured’s physical condition or developmental disability as defined in s. 51.01 (5) (a), Stats.;

Ins 6.54(3)(a)3. 3. The applicant’s or insured’s past mental disability;

Ins 6.54(3)(a)4. 4. The applicant’s or insured’s age;

Ins 6.54(3)(a)5. 5. The applicant’s or insured’s marital status;

Ins 6.54(3)(a)6. 6. The applicant’s or insured’s sexual preference;

Ins 6.54(3)(a)7. 7. The applicant’s or insured’s “moral” character.

Ins 6.54(3)(b) (b) Nothing in par. (a) shall be construed as including within the definition of prohibited practices any of the following:

Ins 6.54(3)(b)1. 1. Denying, cancelling or non-renewing the automobile or property insurance of a person convicted of an offense if the offense which resulted in the conviction is directly related to the risk to be insured;