DEPARTMENT OF INSURANCE

DEPARTMENT OF INSURANCE

Affiliations

Name	Cusick, Thomas Patrick	DOIID	522993	NAIC NPN	1123296

License - Line of Authority Information

Status	Residency	Class	Line of Authority	Active Date	Inactive Date	License Expiration Date
Inactive	Non Resident	Administrator	Not Applicable	4/20/2001	3/31/2005
Inactive	Non Resident	Agent	Health	4/9/2001	3/31/2005
Inactive	Non Resident	Agent	Life	4/9/2001	3/31/2005
* If a status Is Pending, Pending Replacement,Or the record displays Affidavit On File, click On them For more details.

Appointments with the following Insurers

Status	Affiliation Name	DOI Number	Line of Authority	Active Date	Inactive Date
Inactive	Allianz Life Insurance Company of North America	301791	Agent - Health	4/8/2003	3/31/2005
Inactive	Allianz Life Insurance Company of North America	301791	Agent - Life	4/8/2003	3/31/2005
Inactive	American Fidelity Assurance Company	301004	Agent - Health	4/9/2001	12/22/2004
Inactive	American Fidelity Assurance Company	301004	Agent - Life	4/9/2001	12/22/2004
Inactive	Provident Life and Accident Insurance Company	301525	Agent - Health	12/6/2001	3/31/2005
Inactive	Provident Life and Accident Insurance Company	301525	Agent - Life	12/6/2001	3/31/2005

Designated to act on behalf of the following Business Entities

Status	Affiliation Name	DOI Number	Line of Authority	Active Date	Inactive Date
Inactive	Benefit Planners Limited LLP	523411	Administrator - Not Applicable	4/20/2001	3/31/2005
Inactive	Medlink Inc	400721	Agent - Health	9/24/2002	3/31/2005
Inactive	Medlink Inc	400721	Agent - Life	9/24/2002	3/31/2005