DEPARTMENT OF INSURANCE

DEPARTMENT OF INSURANCE

Affiliations

Name	Stivers, Janice Helen	DOIID	334008	NAIC NPN	7182771

License - Line of Authority Information

Status	Residency	Class	Line of Authority	Active Date	Inactive Date	License Expiration Date
Inactive	Resident	Agent	Health	9/7/1994	9/30/2009
Inactive	Resident	Agent	Prepaid Dental Plan	9/22/2000	3/1/2001
Inactive	Resident	Agent	Life	9/7/1994	9/30/2009
AFFIDAVIT ON FILE
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Appointments with the following Insurers

Status	Affiliation Name	DOI Number	Line of Authority	Active Date	Inactive Date
Inactive	American Family Life Assurance Company of Columbus (AFLAC)	301781	Agent - Health	12/10/2001	3/18/2003
Inactive	American Family Life Assurance Company of Columbus (AFLAC)	301781	Agent - Life	12/10/2001	3/18/2003
Inactive	First Colony Life Insurance Company	301179	Agent - Health	9/7/1994	3/31/1997
Inactive	First Colony Life Insurance Company	301179	Agent - Life	9/7/1994	3/31/1997
Inactive	Metropolitan Life Insurance Company	301948	Agent - Health	5/1/1995	10/16/2006
Inactive	Metropolitan Life Insurance Company	301948	Agent - Life	5/1/1995	10/16/2006

Designated to act on behalf of the following Business Entities

Status	Affiliation Name	DOI Number	Line of Authority	Active Date	Inactive Date
Inactive	Samsil & Holland, LLC	510802	Agent - Life	7/14/2000	10/16/2006
Inactive	Samsil & Holland, LLC	510802	Agent - Health	7/14/2000	10/16/2006
Inactive	Samsil & Holland, LLC	510802	Agent - Prepaid Dental Plan	9/22/2000	3/1/2001
Inactive	Stivers Financial Group Inc.	399253	Agent - Life	11/14/1994	5/31/2004
Inactive	Stivers Financial Group Inc.	399253	Agent - Health	11/14/1994	5/31/2004