SERFF Advisory Board Candidate Application Package

The SERFF Advisory Board Application consists of three parts:

1) Part I – Acknowledgement of Responsibilities/Signature (Page 1) 2) Part II – The Application (Pages 2 and 3) 3) Part III – A Professional Biography (Supplement)

Acknowledgement of Responsibilities/Signature – Part I

The SERFF Advisory Board (SAB) member responsibilities are described in the SERFF Advisory Board Operating Procedures adopted by the NAIC membership on 8/25/13. (http://www.serff.com/documents/contact_serff_board_psc_listing.pdf)

The SAB meets at NAIC National Meetings which occur three times per year. (Registration for the National Meeting is not required to attend the SAB meeting as a Board member.)

Applicants should be aware that the NAIC does not fund the travel to any SERFF Advisory Board meetings at this time.

Please review the SERFF Advisory Board Operating Procedures and sign below, indicating your acknowledgement of SAB member responsibilities and your intent to apply for a SERFF Advisory Board position.

______Signature

Name First Name MI Last Name

Employer Name

Your Title

Address

Type of business or organization

Board Member Position Applying For:

Industry Consumer Representative

Please list other professional boards and committees that you serve on, or have served on. Organization Role/Title Dates of Service

Education/Training/Certificates:

How do you feel the SERFF Advisory Board would benefit from your involvement on the Board?

Please list any groups, organizations or businesses that you could serve as a liaison to on behalf of the SERFF Advisory Board.

Please tell us anything else you’d like to share.

Professional Biography

Separately, please provide a bio describing your professional career.

Thank you very much for applying.