DEPARTMENT OF INSURANCE

DEPARTMENT OF INSURANCE

Affiliations

Name	Basak, Sandra	DOIID	669297	NAIC NPN	1030878

License - Line of Authority Information

Status	Residency	Class	Line of Authority	Active Date	Inactive Date	License Expiration Date
Inactive	Non Resident	Agent	Health	11/30/2007	6/30/2009
Inactive	Non Resident	Agent	Life	11/30/2007	6/30/2009
* 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	Provident Life and Accident Insurance Company	301525	Agent - Health	1/29/2008	6/30/2009
Inactive	Provident Life and Accident Insurance Company	301525	Agent - Life	1/29/2008	6/30/2009
Inactive	Reliance Standard Life Insurance Company	300584	Agent - Health	7/2/2008	6/30/2009
Inactive	Reliance Standard Life Insurance Company	300584	Agent - Life	7/2/2008	6/30/2009
Inactive	UNUM Life Insurance Company of America	300817	Agent - Health	1/29/2008	6/30/2009
Inactive	UNUM Life Insurance Company of America	300817	Agent - Life	1/29/2008	6/30/2009

Designated to act on behalf of the following Business Entities

Status	Affiliation Name	DOI Number	Line of Authority	Active Date	Inactive Date
Inactive	Mercer Health & Benefits LLC	607080	Agent - Health	4/30/2008	6/30/2009
Inactive	Mercer Health & Benefits LLC	607080	Agent - Life	4/30/2008	6/30/2009