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054.00.91 Appendix A. Service Contract Provider Registration Form.

AR ADC 054.00.91 Appendix AArkansas Administrative Code

West's Arkansas Administrative Code
Title 054. Insurance Department
Division 00.
Rule 91. Creating a Legal Framework Within Which Service Contracts Are Defined, Sold and Regulated
Ark. Admin. Code 054.00.91 Appendix A
054.00.91 Appendix A. Service Contract Provider Registration Form.
Currentness
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__________
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 054.00.91 Appendix A, AR ADC 054.00.91 Appendix A
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