MN Service Contract Provider Form

SERVICE CONTRACT PROVIDER REGISTRATION APPLICATION

MN DEPARTMENT OF COMMERCE
Commerce & Industry Services
85 7th Place East, Suite 500 • St. Paul, MN 55101-2198

REGISTRATION FEE = $750

1. Name of Provider:

Principal Business Street Address:

City: State: Zip:

Contact Person: Email Address:

Telephone Number: Fax:

2. Domicile and Date of Incorporation of Provider:

3. Name and Contact Information for Provider’s Representative to Handle Inquiries in Service Contracts sold in Minnesota (if different than contact person in item one):

Name: Email Address:

Principal Business Street Address:

City: State: Zip:

Telephone Number: Fax:

4. Name and Contact Information of Administrator(s) of Service Contracts (if any are appointed):

5. List the Parent and any Affiliate Entities of Provider engaged in the service contract business (attach additional sheets if necessary):

6. List the States in Which Provider is, or at any Time was engaged in the Business of a Service Contract Provider:

7. Are There any Formal or Informal Regulatory Actions, Pending or which have been taken against the Provider by any Governmental Agency within the last ten years?

Yes No (If yes, attach a detailed explanation of the action)

FINANCIAL REQUIREMENTS

8. Identify the Method by which the Provider Intends to Ensure the Faithful Performance of its Obligations under its Service Contracts:

a. Insure all service contracts under a reimbursement policy. Please provide the name of the insurer, risk retention group or surplus lines carrier issuing the policy, attach a copy of the policy, and a statement signed by the authorized representative of the entity issuing the policy that they comply with Minn. Stat. § 59B.03, subd. 4(1), audited financial statement pursuant to Minn. Stat. § 59B.03, subd. 4(1) (i) or, in the alternative, evidence of compliance with Minn. Stat. § 59B.03, subd. 4(1) (ii); OR

b. Funded reserve account and financial security deposit. Provide documentation showing the location and type of deposit to be placed in trust with the Commissioner as set forth in Minn. Stat. § 59B.03, subd. 4(2) (ii). If using a bond, a copy of the bond is acceptable; OR

c. $100,000,000 Net-Worth. Submit provider’s or provider’s parent company’s most recent Form 10-K or Form 20-F or most recent audited financial statement as required under Minn. Stat. § 59B.03, subd. 4(3) (ii).

CERTIFICATION

With knowledge of the penalties for false statements, I certify that all information submitted on this application is true and correct and that:

• The undersigned is authorized to sign on behalf of the applicant.

• Applicant will comply with the Minnesota Service Contract Law (Minn. Stat. Chapter 59B) and any service contracts sold in Minnesota will meet all requirements set forth in the law.

• Applicant agrees to make available all records required to be maintained under the Act.

• Applicant has and will maintain the financial requirements pursuant to Minn. Stat. §59B.04 Subd. 4

Revised 10/09