A.Personalname:Address:Telephone

APPLICATIONFORFIRST-TIMEANDFIRST-YEARFUNDEDCONSUMERREPRESENTATIVE

TOPARTICIPATEASACONSUMERREPRESENTATIVEATNAICMEETINGSANDTORECEIVEREIMBURSEMENTFOREXPENSESFROMNAIC

FORTHEYEAR2016

I.GENERALINFORMATION

A.PERSONALNAME:ADDRESS:TELEPHONE:

FACSIMILENUMBER:E-MAILADDRESS:

B.EMPLOYMENT

PLACEOFEMPLOYMENT:POSITION:

ADDRESS:

TELEPHONENUMBER:FACSIMILENUMBER:

E-MAILADDRESS:

C.EDUCATION

II.MEETINGPARTICIPATION

A.ThreeNAICnationalmeetingsareheldannuallyandgenerallylast3to5days.Whilesomemeetingsbeginonaweekend,othersbeginonaweekday.Ineitherinstance,participationinaNAICnationalmeetingrequiresattendanceand/ortravelontwotofourbusinessdays.ThefutureNAICnationalmeetingscheduleisavailableonlineat: Yes No

B.Areyouwillingandabletospendadditionaltimeresearchingissuesandparticipatingininterimconferencecallsandothermeetings? Yes No

C.WhydoyouwanttorepresenttheconsumerinterestinpolicydiscussionsattheNAIC?

III.DEMONSTRATEDEXPERTISEANDEXPERIENCE

FirstTimeApplicants:

A.TobeaneffectiveconsumerrepresentativeinNAIC,onemustbeabletoanalyzetheissuesandcommunicatetheconsumerposition.Whatskillsdoyouhavethatwouldenableyoutodothat?

B.Whatexperienceshaveyouhadthatqualifyyoutorepresenttheconsumerviewininsuranceissues?Relevantexperiencemaybevaried.Somewouldincludetestifyingonbehalfofconsumers,participatinginpolicydiscussions,conductingresearchandformulatingrelevantrecommendations,oreducatingconsumerstoimprovetheirmarketplaceexperiences.

C.Whatinvolvement,ifany,haveyoualreadyhadwithNAIC?RelevantexperienceswouldincludereviewingwritteninformationfromNAIC,attendingNAICmeetings,providingtestimony,submittingwrittencomments,andworkingwithanNAICmemberorstaffonanissue.

D.Whatinvolvement,ifany,haveyouhadwiththestateinsurancedepartments?

E.Attachtoyourapplicationacopyofyourresumeandotherpertinentinformation.

ApplicantswhoservedasNAICconsumerrepresentativespreviously:

A.ListtheNAICNationalMeetingsandinterimmeetingsyouattendedthispastyear.

B.WhatwasyourprimaryfocusattheNAICthispastyear;i.e.,healthinsurance,lifeinsurance,propertycasualtyinsurance,financialsolvency,marketregulation?

C.Forthearea(s)ofyourprimaryfocus,didyousubmitwrittencommentsorproposalsthispastyear?Ifso,pleaselisttheNAICCommitteesandWorkingGroupstowhichyoumadecomments.

D.Forthearea(s)ofyourprimaryfocus,didyouprovideoralcommentsduringNAICmeetingsthispastyear?Ifso,pleaselisttheNAICCommitteesandWorkingGroupstowhichyoumadecomments.

E. DidyougiveformalpresentationsatanyoftheNAICNationalMeetingsorinterimmeetings?Ifso,pleaselistthemeetingsatwhichyoumadepresentationsandthesubjectmatterorissueforwhichyouconductedresearchandformulatedrecommendations.

F.DidyouparticipateinNAICinterimconferencecalls?Ifso,pleaseprovidetheNAICCommitteeorWorkingGroupnameandestimatethenumberofcalls.

G.WhatinteractionhaveyouhadwiththestateinsurancedepartmentsthispastyearoutsidetheNAICnationalmeetings?

H. Pleaselistanyotheractivitiesthatyoubelievehelpexplainyourcontributionsmadeasan

NAICfundedconsumerrepresentative.

I. Are you interested in participatingin the administrativefunctionsof the Consumer

ParticipationprogrambyservingasamemberoftheBoardofTrustees? Yes No

(ThisopportunityisopenonlytothosewhohaveservedatleastoneyearasanNAICFundedConsumerLiaisonRepresentative.)Boardmembershiprequiresanadditionalcommitmentoftimeandresources,includingparticipationinpersonandintelephonemeetingsaswellasregulare-mailcorrespondence;takingleadershipfororganizingandcommunicating regardingagendasfortheNAIC/ConsumerLiaisonCommittee,includingsettingtimeschedulesandmeetingsamongtheconsumerrepresentatives,communicatingwithregulators;andcoordinatingwithNAICstaff.

Ifyouareinterested,pleasewriteabriefstatementbelowtoexplainyourinterest.Alsopleasenotethatconsumermembersoftheboardareselectedbyregulatormembersoftheboard.

IV.CONFLICTOFINTEREST

A. Areyou,anymemberofyourimmediatefamilyoranyonelivinginyourhouseholdemployedonafull-time,part-timeorcontractualbasisbyanyinsuranceentityorpersonregulatedbyastateinsurancedepartment,insuranceagency,tradeassociation,oradvisoryorratingorganization? Yes No

Ifyes:

a.Identifyemployedpersonandrelationshiptoyoub.Employer(s)?

c.Full-time,part-time,orcontractual?

d.Ifpart-timeorcontractual,ongoingoroccasional?

e.Dollaramountreceivedfromeachemployeroverthepastthreeyears? Basisforpayment(hourly,projectbased,etc.)

f.Natureofthework(hoursspent,servicesprovided)

B. Doyou,anymemberofyourimmediatefamilyoranyonelivinginyourhouseholdreceivecompensation(otherthanthroughemployment)fromanyinsuranceentityorpersonregulatedbyastateinsurancedepartment,insuranceagency,tradeassociation,oradvisoryorratingorganization? Yes No

Ifyes:

a.Identifytheindividualreceivingcompensationandrelationshiptoyoub.Source(s)ofcompensation?

c.Isthecompensationongoingoroccasional?

d.Dollaramountreceivedfromeachsourceoverthepastthreeyears?

e.Basisforpayment(stipend,travelreimbursement,dependentonservices,etc.)

f.Expectationsonwhichcompensationisbased

V. DIVERSITY

TheNAICstrivestoachievediversityamongitsconsumerrepresentatives.Answeringthefollowingquestionisoptional.Whatisyourracial/ethnicbackground?

VI.INFORMATIONABOUTTHEORGANIZATIONYOUREPRESENT

A.NAMEOFORGANIZATION:ADDRESS:

TELEPHONENUMBER:FACSIMILENUMBER:

E-MAILADDRESS/WEBSITEADDRESS:B.Isthisanon-profitorganization? Yes No

C.Isthisamembershiporganization? Yes No Ifyes,whatisthesize?

DHowdoesyourorganizationdisseminateinformationtoconsumers?Howmanyconsumersdoyoureach?

E. Pleasedescribethespecificwaysinwhichyourorganizationisinvolvedininsuranceissues.

F. Whatconstituencydoesyourorganizationrepresent?

G. Describeyourorganization’smissionandgoals.

H.Pleaseattachacopyofyourorganization’sbudgetforthecurrentyear.PleaseprovidesufficientdetailonsourcesoffundingandneedforNAICfinancialsupport.

PleaseindicateiftheorganizationyouwillberepresentingatNAICacceptsfinancialsupportfromanyofthefollowing:

1.Anyinsurancecompanyoragency? Yes No

2.Anypersonorentityregulatedbyastateinsurancedepartment? Yes No

3.Anylobbyinggroupand/orentitythatlobbiesoradvocatesonbehalfofanyperson,organization,and/orentityregulatedbyastateinsurancedepartment? Yes No

4.Anyinsurancetradeassociationorinsuranceadvisoryorratingorganization?

Yes No

Ifyouansweredintheaffirmativeonitems1,2,3,or4above,pleaseprovidepertinentdocumentationincluding:

1.Source(s)offinancialsupport?

2.Isfundingongoingoroccasional?

3.Dollaramountreceivedfromeachsourceoverthepastthreeyears?

4.Expectationsonwhichfundingisbased

VII.REQUIRESFUNDING

Inadditiontotheregistrationfee,theaverageout-of-pocketmonetarycostofattendinganNAIC

nationalmeetingis$1,500.WhydoyourequireNAICfundinginordertoparticipate?

Acompleteapplicationmustinclude:

•Acurrentcopyofyourresumealongwithanyotherpertinentinformation,suchasorganizationpublications,testimony,referencesorlettersofrecommendation;and

•Asignedconflictofintereststatement;and

•Acopyofyourorganization’sbudget.

Theinformationcontainedinandsubmittedwiththisapplicationistrueandcompletetothebestofmyknowledge.

SignatureDate

PLEASERETURNTHECOMPLETEDAPPLICATIONTOMEBY5:00P.M.(CENTRAL)ONOCTOBER31,2015.

ELECTRONICSUBMISSIONSAREENCOURAGED.

LoisE.Alexander,CFE,FLMI,HIA,ACP

MarketRegulationManager

NationalAssociationofInsuranceCommissioners

1100WalnutStreet,Suite1500

KansasCity,MO64108

Telephone:(816)783-8517

Facsimile:(816)460-7632

E-Mail:

ADDENDUMTO

CONSUMERREPRESENTATIVEAPPLICATIONCONFLICTOFINTERESTSTATEMENTJULY16,2014

ConsumerrepresentativesappointedbytheNAICareexpectedtoeffectivelyrepresenttheinterestsandviewpointsofconsumers.ConsumerrepresentativesshallnotpurporttorepresenttheviewsoftheNAIC.

Effectiveconsumerrepresentationmaybecompromisediftheconsumerrepresentativereceivedcompensationfromaregulatedentity.

Definition:Forthepurposesofthisdocument,“aregulatedentity”means,“aregulatedentityofstateinsuranceregulators,itstradegroup,orotherentitiesorindividualsactingasagentsorrepresentativesofaregulatedentity.”

Application:AllapplicantsfortheNAICConsumerParticipationprogramareexpectedtocompletetheapplicationfullyandaccurately,includingthequestionaboutindustrycompensationandpotentialconflictsofinterest.TheConsumerBoardofTrusteeswillevaluatetheamountandpurposeoftheindustryexpensereimbursementandcompensation,ifany,anddeterminewhetheritrepresentsaconflictofinterest.

Disclosure:TheconsumerrepresentativemustnotifytheChairoftheConsumerBoardofTrusteesandtheNAICstaffpersonprovidingsupporttotheConsumerBoardofTrusteesif,atanytimeduringanindividual’stermasanNAIC-appointedconsumerrepresentative,aregulatedentityprovidesoragreestoprovidecompensationtotheconsumerrepresentative’sorganization;theconsumerrepresentativeoranimmediatefamilymemberoftheconsumerrepresentative,includingspouse,domesticpartner,parents,siblingsandchildren.Suchnotificationmustoccurbyemailwithinsevendaysofthereceiptofcompensationortheofferofacompensationagreement,whicheverisearlier.

ConflictDetermination:TheConsumerBoardofTrusteeswilldeterminewhetherthecompensationreceivedortheofferofacompensationagreementconstitutesaconflictofinterestbasedondiscussionandestablishedguidelines.

Guidelines:GuidelinestheBoardwilluseinitsevaluationinclude,butarenotlimitedto,thefollowing:

•Expense reimbursement from a regulated entity for actual travel expenses, includingtransportation,lodgingandmeals,generallydoesnotrepresentaconflictifthetravelisrelatedtorepresentationofinsuranceconsumerinterests.Disclosureofsuchexpensereimbursementsisnotrequired.

•Employment income, fees for services provided to regulated entities (eg providing experttestimonyonbehalfofregulatedentitiesevenifcompensationisreceivedfromalawfirm),orothercompensationreceivedfromaregulatedentitymaybeaconflict(unlessitisanexpensereimbursementforactualtravelexpensesfortheconsumerrepresentativeapplicant)andmustbedisclosedtotheboard.

•Receiptofgiftsfromaregulatedentityvaluedatgreaterthan$50.00perappointmentyearoratotalofmorethan$250.00fromallregulatedentitiesintheappointmentyearareconsideredaconflictofinterestandmustbedisclosed.

•Stipendsorhonorariareceivedfromaregulatedentitymaybeaconflictofinterestandmustbedisclosed.

Confidentiality:MembersoftheConsumerBoardofTrusteesmustkeepconfidentialallfinancial,personal,andbusinessinformationsubmittedbytheconsumerrepresentativeapplicant.ConsumerBoardofTrusteediscussionsregardingpotentialconflictswillremainconfidential.ConsistentwithmaintainingtheintegrityoftheConsumerParticipationProgram,onlycontactinformationandconsumerfocus,or,line(s)ofbusinessrepresentedbytheconsumerrepresentativeapplicantwillbemadepublic.

Certification:IcertifythatIhavereceived,readandunderstoodthisNAICConsumerRepresentativeApplicationConflictofInterestStatement.IalsounderstandthatthepurposeofmysignatureonthisStatementistoprotecttheintegrityofthemissionoftheNAIC’sConsumerParticipationPlan.

AsstatedinSection1ofthePlanofOperationsfortheNAICConsumerParticipationProgram,themissionoftheNAICConsumerParticipationProgramistoassisttheNAICinitseffortstosupportstateinsuranceregulationbyprovidingconsumerviewsoninsuranceregulatoryissues.Aqualifiedconsumerorganizationisanational,state,orlocalorganizationthatservestoprotecttheinterestsofconsumersastheyrelatetotheregulationofinsurance.Theirparticipationisbasedontheirdesiretocollectand/orimpartinformationofmutualconcernandinteresttoinsuranceregulatorsandthatrepresentsaconsumerperspective.Onemeasureofwhetheranorganizationrepresentsaconsumerperspectiveisitssourceoffunding.

StatementofUnderstanding:IfurtherunderstandthatifIamappointedbytheNAICConsumerBoardofTrusteestobeaconsumerrepresentativethatIamindicatingbymysignatureonthisformthatIunderstandandagreetoabidebythisStatement.

SignatureofNAICRepresentativeApplicantDate

PrintedNameofNAICRepresentativeApplicant