23 CAR pt. 36, Appendix A. Forms

Arkansas Insurance Department 1200 West Third Street, Little Rock, AR 72201-1904 SERVICE CONTRACT PROVIDER REGISTRATION FORM Unless exempt, a provider of a service contract in Arkansas issued on or after October 1, 2007 is required to register with the Arkansas Insurance Department. For information on service contracts, see Arkansas Code Annotated §§ 4-114-101, et seq. and Arkansas Insurance Department Rule 91. Return Completed Form with Registration Fee to: Arkansas Insurance Department, Finance Division 1200 West Third Street, Little Rock, Arkansas 72201-1904 501-371-2665, Fax 501-371-2747 http://www.insurance.arkansas.gov/finance/divpage.htm Registration Information _____ Original Registration or _____ Annual Renewal Registration _____ $200 Registration Fee Enclosed. Check made payable to: State Insurance Department Trust Fund. Provider Identification Information 1. Legal Name of Provider: _______________________________________________________ Trade Name (if different) _______________________________________________________ Principal Business Street Address: ________________________________________________ City: ____________________ State: ____________________ Zip Code: ________________ Contact Person: ____________________________ E-mail Address: _____________________ Telephone Number: ______________________ Facsimile Number: _____________________ 2. Domicile of Provider: _____________________________________ 3. Name and Contact Information for Provider’s Representative to handle inquiries in Service Contracts Sold in Arkansas (if different than the contact person listed in item number one): Name: ___________________________ E-mail Address: _____________________________ Principal Business Street Address: ________________________________________________ City: ____________________ State: ____________________ Zip Code: ________________ Telephone Number: ______________________ Facsimile Number: _____________________ 4. List the States in which the Provider is engaged in the business of providing Service Contracts: ____________________________________________________________________________ 5. Are there any administrative or regulatory actions that have been taken or our pending against the Provider by any governmental agency within the last ten (10) years? _____ Yes _____ No If yes, attach a detailed explanation of any such actions. Renewal Information If this is a renewal registration, please note any material changes that have occurred subsequent to the filing of your most recent registration: ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ________________________________________________________ Compliance with Financial Requirements __________________________ (Provider’s Name) has chosen to comply with the obligations imposed by Ark. Code Ann. § 4-114-104(d), under one of the options checked below: 1.____ All service contracts are insured under a reimbursement insurance policy that meets the requirements of Ark. Code Ann. § 4-114-104(d)(1). (Submit a copy of the active policy) 2. _____ A funded reserve account is maintained that meets the requirements of Ark. Code Ann. § 4-114- 104(d)(2). (Provide documentation of the funded reserve account showing that it meets the requirements of Ark. Code Ann. § 4-114-104(d)(2)) 3. _____ A financial security deposit that meets the requirements of Ark. Code Ann. § 4-114-104(d)(3) of not less than 5% of gross considerations received less claims paid, but not less than $25,000, consisting of a surety bond issued by an authorized surety. (Provide proof that your security deposit meets the minimum requirements and complete the attached Service Contract Provider Bond Form) 4. _____ Maintain a net worth of $100,000,000 pursuant to the requirements of Ark. Code Ann. § 4-114- 104(d)(4). Submit the Provider’s or Providers Parent’s most recent 10K or Form 20F filed with the SEC or audited financial statement. If the financial responsibility requirement under this paragraph is to be maintained by the Provider’s parent company, the parent company shall guarantee the Provider’s obligations under service contracts sold by the Provider in this State. Submit a written guarantee agreement signed and notarized by an officer of the parent company to this effect. Provider Certification STATE OF __________________ ) ) COUNTY OF _________________ ) I, the undersigned, state under oath that I have duly executed this registration, for and on behalf of _______________________ (Provider Name), and that I hold the executive position of _______________________ (Title) of such Provider, and that I am authorized to execute and file this registration. I, the undersigned, further state that I am familiar with this instrument, including all documents related to this registration and the contents thereof, and that the facts herein set forth are true to the best of my knowledge, information and belief. I hereby certify that the Provider named herein is in compliance with all requirements of the Service Contracts Act, Ark. Code Ann. §§ 4-114-101, et seq. I further certify that the service contracts issued by the Provider named herein comply with the disclosure requirements of Ark. Code Ann. § 4- 114-106. Signature Print Name Date Notary Information The foregoing instrument was signed and acknowledged before me on this _____ day of _________ by _________________________, personally known or made known to me. (Notary Public) My Commission Expires ARKANSAS INSURANCE DEPARTMENT SERVICE CONTRACT PROVIDER BOND FORM BOND NO. ___________________ KNOW ALL MEN BY THESE PRESENTS: That we, _____________________________________________________ , as Principal, a corporation organized under the laws of the State of ____________________________________ , and __________________________________________________ , a corporation as Surety, organized and existing under the laws of the State of ____________________ and duly authorized to transact the business of surety in the State of Arkansas, are held and firmly bound unto the Commissioner of Insurance of the State of Arkansas in the sum of not less than five percent (5%) of the gross consideration received, less claims paid, on the sale of the service contract for all service contracts issued and in force, but not less than Twenty-Five Thousand Dollars ($25,000), for the benefit of any person referred to in the conditions of this bond for which payment, well and truly made, we hereby bind ourselves, our successors and assigns, jointly, severally and firmly by these presents. The conditions of the above obligation are such that: WHEREAS: The said Principal has applied to the Commissioner of Insurance of the State of Arkansas for authority as a service contract provider, and in accordance with the provisions of Arkansas Code Title 4 Chapter 114, as amended, is required to give a corporate surety bond for the benefit of any contract holder who may suffer loss resulting from fraud or dishonesty or insolvency or impairment or unwillingness to perform on the part of said Principal. NOW THEREFORE, if the said Principal shall promptly pay, when due, all claims and obligations arising or occurring in this state by virtue of any bond or contract made by said Principal, and all amounts due the State of Arkansas, by virtue of any statute, and in all respects comply with Arkansas Code Title 4 Chapter 114 of the laws of said State, then this obligation shall become void, otherwise to remain in full force and effect. The total aggregate liability under this bond is limited to the sum of $ ___________________. This bond shall be deemed continuous in form and shall remain in full force and effect unless terminated or cancelled in a manner hereinafter provided. By order of said Commissioner of Insurance; or By the Surety delivering thirty (30) day written notice to the Arkansas Insurance Department that the bond will be canceled. Such cancellation or termination shall not affect any liability incurred or accrued hereunder prior to the termination or cancellation of said bond by said Department of Insurance or prior to the termination of the thirty (30) day period for notice if terminated by Surety. WITNESS our hands and seal this _________ day of ________________________ , ________. By: ______________________________________ (Principal) By: ______________________________________ (Surety)