DEPARTMENT OF INSURANCE

PUBLIC PROTECTION
CABINET

DEPARTMENT OF INSURANCE

Affiliations

Name	Gustafson, Gary D	DOIID	650803	NAIC NPN	7745468

License - Line of Authority Information

Status	Residency	Class	Line of Authority	Active Date	Inactive Date	License Expiration Date
Inactive	Non Resident	Agent	Life	3/7/2007	9/30/2014
Inactive	Non Resident	Agent	Health	3/7/2007	9/30/2014
* 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	Fidelity Investments Life Insurance Company	300620	Agent - Health	9/25/2008	10/2/2012
Inactive	Fidelity Investments Life Insurance Company	300620	Agent - Life	9/25/2008	10/2/2012

Designated to act on behalf of the following Business Entities

Status	Affiliation Name	DOI Number	Line of Authority	Active Date	Inactive Date
Inactive	Fidelity Employer Ins Services Inc	653192	Agent - Life	10/6/2009	10/2/2012
Inactive	Fidelity Employer Ins Services Inc	653192	Agent - Health	10/6/2009	10/2/2012
Inactive	Fidelity Insurance Agency Inc.	400221	Agent - Life	4/8/2011	10/2/2012
Inactive	Fidelity Insurance Agency Inc.	400221	Agent - Health	4/8/2011	10/2/2012