DEPARTMENT OF INSURANCE

DEPARTMENT OF INSURANCE

Affiliations

Name	Thomerson, Keith H	DOIID	381397	NAIC NPN	103722

License - Line of Authority Information

Status	Residency	Class	Line of Authority	Active Date	Inactive Date	License Expiration Date
Inactive	Resident	Agent	Health Maintenance Organization	8/9/1995	3/1/2001
Inactive	Resident	Agent	Life	4/2/1992	4/7/2008
Inactive	Resident	Agent	Health	4/2/1992	4/7/2008
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 United Life Insurance Company	300498	Agent - Health	1/29/1996	5/19/1997
Inactive	American United Life Insurance Company	300498	Agent - Life	1/29/1996	5/19/1997
Inactive	Anthem Health Plans of Kentucky, Inc.	300999	Agent - Health	3/1/2001	4/1/2002
Inactive	Anthem Health Plans of Kentucky, Inc.	300999	Agent - Health Maintenance Organization	8/9/1995	3/1/2001
Inactive	Bankers Life and Casualty Company	300701	Agent - Health	4/2/1992	4/3/1996
Inactive	Bankers Life and Casualty Company	300701	Agent - Life	4/2/1992	4/3/1996
Inactive	Illinois Mutual Life Insurance Company	301479	Agent - Health	3/14/1996	12/27/2000
Inactive	Illinois Mutual Life Insurance Company	301479	Agent - Life	3/14/1996	12/27/2000
Inactive	Paul Revere Life Insurance Company	300971	Agent - Health	4/1/1998	8/24/2000
Inactive	Paul Revere Life Insurance Company	300971	Agent - Life	4/1/1998	8/24/2000
Inactive	Pioneer Life Insurance Company	300110	Agent - Health	5/15/1996	10/23/2002
Inactive	Pioneer Life Insurance Company	300110	Agent - Life	5/15/1996	10/23/2002
Inactive	Principal Life Insurance Company	300129	Agent - Health	4/15/1996	4/7/2008
Inactive	Principal Life Insurance Company	300129	Agent - Life	4/15/1996	4/7/2008
Inactive	Provident Life and Accident Insurance Company	301525	Agent - Health	4/25/1996	11/10/2004
Inactive	Provident Life and Accident Insurance Company	301525	Agent - Life	4/25/1996	11/10/2004
Inactive	Stonebridge Life Insurance Company	301614	Agent - Health	5/8/1997	4/13/1998
Inactive	Stonebridge Life Insurance Company	301614	Agent - Life	5/8/1997	4/13/1998

Designated to act on behalf of the following Business Entities

Status	Affiliation Name	DOI Number	Line of Authority	Active Date	Inactive Date
Inactive	Acordia Senior of The Southeast Inc.	401297	Agent - Life	7/25/1995	2/10/2004
Inactive	Acordia Senior of The Southeast Inc.	401297	Agent - Health	7/25/1995	2/10/2004
Inactive	Healthplan Services, Inc.	401230	Agent - Health	8/31/1995	3/31/1997