(To be filed with the State Insurance Commissioner, State of Arkansas on or before January 1, 1988, and on the same date of each year thereafter.)

AFFIANT, __________, Credit Insurance Agent for __________ hereby declares upon oath that for the year ending __________ this credit insurance agent has not received or agreed to receive any compensation in excess of reasonable compensation as defined in Rule & Regulation 12 of the Arkansas Insurance Department as defined therein.

The presumed reasonable compensation of forty per cent (40%) of the net written life insurance premiums and of the net written disability insurance premium allowed to be paid to defined recipients is further defined as follows:

“Compensation” shall include, but not be limited to, the receipt directly or indirectly or reciprocally of commission, contingent commissions, service fees, policy fees, expense allowances or reimbursements, dividends or other distribution of earnings based solely upon the profits derived from issuing or reinsuring any policy of credit life or credit disability insurance procured, issued, or delivered by such creditor, agent or limited insurance representative, gifts, all benefits such as items of merchandise, equipment, travel, conventions, vacations, rewards, bonuses, trading stamps, scripts, or any other form of remuneration resulting directly or indirectly from the sale of credit insurance or as an inducement to or payment for sales made or volume of sales obtained. Experience refunds, retrospective rate credits, and dividends are treated as compensation for the sole purpose of determining presumptively reasonable compensation allowances under this section. Compensation shall also include any amounts or things of value received from or paid by any person other than an insurer in consideration of the sale or retention of credit insurance.

ACKNOWLEDGEMENT

Subscribed and sworn before me this __________ day of __________, 19 ___.

My Commission Expires: __________