Attachment 1A: Application Form (Legal Entities)

ATTACHMENT 1A: APPLICATION FORM

(LEGAL ENTITIES)

This form is to be used by Applicants that are legal entities. This Application is subject to the requirements of the

Request for Qualifications for Special Deputy Receivers ("RFQ").

INSTRUCTIONS

1. Section One must be completed by a person authorized to act on Applicant's behalf.

2. Section Two must be completed by each person designated as a Primary Responsible Person ("PRP").

3. Failure to provide any information may disqualify an Application.

4. Information may be provided in attachments as necessary.

SECTION ONE

I. GENERAL INFORMATION

Description of

Applicant

 Corporation  Partnership  Other (describe)

Full Name of Applicant

Federal Employer

Identification Number

or Taxpayer

Identification Number

Office Address

Mailing Address (if

other than above)

Texas Branch Office

Address (if applicable)

Telephone

Fax

E-mail Address

Website

II. DISCLOSURES

Is Applicant part of an organization that includes affiliated entities? Yes No

If yes, provide the following information regarding any of the affiliates of Applicant:

Name

State/Country of Domicile

Relationship to Applicant

Type of Business

List owners of Applicant (except passive investors) with 10% or more controlling interest:

Name of Owner

Address

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In questions 1 through 14 below, "you" refers to:

a) the Applicant;

b) the Applicant’s proposed PRPs; or

c) any of Applicant’s officers, directors or managers who would be involved in a receivership.

1. Have you been indicted, convicted of, plead guilty, or received deferred adjudication to:

 a felony;

 a misdemeanor involving embezzlement, theft, conversion, larceny, fraud or similar crime;

 a misdemeanor involving violence, workplace misconduct or similar crime;

 a violation of a securities or insurance law; or

 any other crime of moral turpitude?

Yes No

2. Has any indictment or information for any items listed in (1) above been issued against you?

Yes No

3. Has a finding of fraud, breach of fiduciary duty, bad faith, unfair business practices, deceptive trade practices,

conversion or similar action been entered against you by a court or administrative law judge?

Yes No

4. Has any action been filed against you (or a business in which you were an officer, director, or controlling

stockholder) by a receiver, trustee or governmental entity for a breach, failure to perform, or assessment of

penalties or liquidated damages in connection with a contract?

Yes No

5. Have you been subject to any disciplinary proceedings by any governmental or regulatory entity?

Yes No

6. Has a judgment or administrative fines or penalties been imposed against you, or a business in which were an

officer, director, or controlling stockholder?

Yes No

7. Have any of the following actions been taken with respect to an insurer, or other entity involved in the business of

insurance, during the time that you were an officer, director, or controlling stockholder?

 suspension or revocation of a certificate of authority or license;

 administrative oversight;

 supervision;

 conservatorship;

 receivership; or

 any other finding of hazardous condition.

Yes No

8. Are you or any organization in which you have or have had a controlling interest delinquent in filing or paying any

local, state, or federal tax?

Yes No

9. Do you have any actual or potential conflict of interest with the Commissioner of Insurance (“Commissioner”), in

his or her capacity as Receiver or otherwise, including but not limited to any of the following? If so, please

explain in the space provided below Question 13.

 Making a claim or filing an action against TDI or the Commissioner, at any time or presently;

 The filing of an action by TDI or the Commissioner against you, including but not limited to an action to

revoke or suspend a license issued by TDI, at any time or presently;

 Representing or providing services to another party in connection with a claim or action by or against TDI or

the Commissioner, at any time or presently; or

 Representing or providing services to a party, other than the Receiver or an SDR, regarding an insurance

receivership in the State of Texas, at any time or presently.

Yes No

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10. Has a licensing agency or regulatory authority denied an application by you for an occupational or vocational

license or certification, or revoked or suspended such a license held by you?

Yes No

11. Have you been a party to a contract with a receiver, trustee or governmental entity that was terminated for

cause?

Yes No

12. Have you ever been terminated as a Special Deputy Receiver in Texas, or in a similar position in another state?

Yes No

13. Is there any situation similar to those described above, or any other situation that could create any appearance of

impropriety in connection with the Applicant's appointment as a Special Deputy Receiver, at any time or

presently?

Yes No

14. Are you required to register as a lobbyist with the Texas Ethics Commission? If yes, please explain:

Yes No

_________________________________________________________________

If any answer to questions 1-9 is yes, provide applicable information in the space below.

Case or Action

Cause Number

Court (or other forum)

Date Filed / Concluded

If the answer to question 10 is yes, provide applicable information in the space below.

Licensing Agency

License Type

License Number

Date of Action

If any answer to questions 11-12 is yes, provide applicable information in the space below.

Contracting Entity

Contract Type

Contract Date

Date Terminated

If the answer to question 13 is yes, provide applicable information in the space below.

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III. CERTIFICATION

This certification must be executed by a person authorized to act on behalf of the Applicant.

1. Applicant represents that it meets all of the minimum qualifications as described in the Request for Qualifications.

2. Applicant authorizes the release of any and all information, records or other information relevant to the matters

disclosed in this Application, including criminal history information maintained by any state, local or federal law

enforcement entity, to the Commissioner or his or her authorized representatives.

3. Applicant releases the Commissioner and his or her employees and agents from any and all liability, claims, and

lawsuits with respect to the information submitted in this Application or obtained in connection with this

Application. Applicant acknowledges that any and all of the information provided in this Application may be

released by the Commissioner, except as otherwise required by law.

4. Applicant acknowledges that additional information or documentation may be requested by the Commissioner or

his or her authorized representatives, and that a failure to provide any information requested may be cause for

non-approval of this Application.

5. Applicant agrees that it will be bound by the requirements of any Request for Proposals or Agreement regarding

the disclosure of information.

I swear or affirm that I am authorized to act on behalf of the Applicant, that I have read the Request for Qualifications

and this completed Application in their entirety, and that the information submitted in this Application is true and

correct to the best of my personal knowledge and belief.

________________________________________________________ Date: _____________________________

Signature of Applicant's authorized representative

___________________________________________________________________________________________

Title

___________________________________________________________________________________________

Printed Name

NOTICE ABOUT CERTAIN INFORMATION LAWS AND PRACTICES

With few exceptions, you are entitled to be informed about the information that the Texas Department of Insurance

(TDI) collects about you. Under sections 552.021 and 552.023 of the Texas Government Code, you have a right to

review or receive copies of information about yourself, including private information. However, TDI may withhold

information for reasons other than to protect your right to privacy. Under section 559.004 of the Texas Government

Code, you are entitled to request that TDI correct information that TDI has about you that is incorrect. For more

information about the procedure and costs for obtaining information from TDI or about the procedure for correcting

information kept by TDI, please contact the Agency Counsel Section of TDI’s Legal & Compliance Division at (512)

475-1757 or visit the Corrections Procedure section of TDI’s web page at “www.tdi.state.tx.us.” Tex. Gov’t Code

§559.003.

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SECTION TWO

A person who Applicant proposes to designate as a Primary Responsible Person ("PRP") must complete this

section. (If Applicant is designating more than one PRP, this Section must be completed by each PRP.)

I. GENERAL INFORMATION

Full Name of PRP

Address

Mailing Address (if

different from above)

Title

Telephone

Fax

E-mail Address

If the PRP has been an officer, director, principal, partner or controlling stockholder of any corporation, partnership or

other legal entity in the last ten (10) years, provide the information regarding the entity below:

Name of Company

State/Country of Domicile

Position Held

Dates of Service

II. EDUCATION

Type of

School

Name and Location of School

Dates Attended

Graduated

Degree

From

Mo. / Yr.

To

Mo. / Yr.

Yes

No

Colleges or

Universities

Graduate

Schools

Vocational or

Other

 Note: the PRP must have at least a bachelors degree.

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III. EXPERIENCE

1. Indicate if the PRP has at least 10 years work experience. Yes No

2. Indicate if the PRP has experience in any of the following positions. (In this section, the term "receiver" includes

an SDR or any other deputy receiver.)

a) Experience with insurers, HMOs, and other entities in the insurance business, as follows:

 A receiver, conservator, supervisor, or similar appointee in a proceeding of an insurer or other entity in the

insurance business. Yes No

Please list the specific engagement(s), position held and the time period of involvement:

______________________________________________________

 A receiver, trustee, independent fiduciary or similar appointee in a proceeding involving matters related to

insurance. Yes No

Please list the specific engagement(s), position held and the time period of involvement:

______________________________________________________

 An employee or contractor with managerial or other significant involvement in a proceeding described in the

preceding two questions. Yes No

Please list the specific engagement(s), position held and the time period of involvement:

______________________________________________________

 A former insurance regulator or a former employee of such a regulator involved in the overall management,

with experience related to the solvency of insurers. Yes No

Please list the specific engagement(s), position held and the time period of involvement:

______________________________________________________

 A former executive in the insurance business with experience related to insurance regulation. Yes No

Please list the specific engagement(s), position held and the time period of involvement:

______________________________________________________

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 A professional providing service to insurance companies or regulators related to the solvency of insurers.

Yes No

Please list the specific engagement(s), position held and the time period of involvement:

______________________________________________________

Eligible Applicants with PRP(s) meeting the requirements in 2 a) of Section III may submit bids on any RFP for an

SDR as an Applicant, while designating one PRP.

Attach a detailed resume demonstrating all experience responsive to Questions 1 and 2.

3. Does the PRP hold any professional licenses? Yes No

Describe __________________________________________________________________________________

4. Does the PRP hold any relevant certifications, e.g., a designation as a Certified Insurance Receiver (CIR) or

Accredited Insurance Receiver (AIR)? Note: A CIR or AIR designation is not a requirement to be a PRP.

Yes No

Describe __________________________________________________________________________________

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IV. CERTIFICATION

This certification must be executed by the Applicant's proposed PRP.

1. I represent that I meet all of the minimum qualifications for a PRP as described in the Request for Qualifications.

2. I authorize the release of any and all information, records or other information relevant to the matters disclosed in

this Application, including criminal history information maintained by any state, local or federal law enforcement

entity, to the Commissioner or his or her authorized representatives.

3. I release the Commissioner and his or her employees and agents from any and all liability, claims, and lawsuits

with respect to the information submitted in this Application or obtained in connection with this Application. I

acknowledge that any and all of the information provided in this Application may be released by the

Commissioner, except as otherwise required by law.

4. I agree to be bound by the requirements of any Request for Proposals or Agreement regarding the disclosure of

information.

I swear or affirm that I have read the Request for Qualifications and the completed Application in their entirety and

that the information submitted in this Application is true and correct to the best of my personal knowledge and belief.

________________________________________________________ Date: _____________________________

Signature