Service Contract Provider Registration and Renewal Form

Service Contract Provider Registration and Certification

Revised: October 27, 2022

Return this form to:

Department of Financial Regulation

Attn: Company Licensing – Insurance Division

89 Main Street

Montpelier, VT 05620-3101

A. Registrant Identification Information:

1. Name (Must be exact name under which business is being conducted) and FEIN:

2. Named used on service contracts: (if different from 1. above):

3. Telephone Number:

4. Contact Person:

5. Contact Email Address:

6. Mailing Address:

7. Physical Location:

8. Type of Organization (Sole Proprietorship; Partnership; Corporation; LLC, etc.):

9. State of Incorporation:

10. Service of Process Information (8 V.S.A., § 4248(d)): If you are not registered to do business in Vermont with the Vermont Secretary of State, provide the name and address of a person in Vermont upon whom the Service of Process may be served.

Name:

Tel No:

Physical Location:

Mailing Address:

11. Service Contract Reimbursement Reinsurer (name, address, and policy number, if any):

12. Third Party Administrator (name, address, phone number, if any):

13. 3 Year Registration Fee of $600. Make check payable to Department of Financial Regulation.

Should you have any questions, please contact Company Licensing, Insurance Division, via email at DFR.CompLic@Vermont.gov.

B. Certification:

The undersigned certifies and says that he/she has duly executed this registration, for and on behalf of the above Service Contract Organization, and that he/she is authorized to execute and file this registration. The undersigned further states he/she is 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 his/her knowledge, information and belief and he/she hereby certifies that the Service Contract Organization is in compliance with Title 8, Chapter 113, Subchapter 4, Vermont Statutes Annotated, as amended to include that:

1. The proof of financial stability requirements of § 4249 are being met;

2. If a service contract reimbursement policy or policies are being submitted as proof of financial stability, the policy or policies cover all contract holders in the State of Vermont;

3. The consumer disclosure requirements of § 4251 are being met;

4. The obligations of providers and insurers of § 4252 are being met;

5. The prohibited acts of § 4253 are not being done and;

6. The prohibited terms of § 4254 are not being used.

I AM A NATURAL PERSON AUTHORIZED TO SIGN ON BEHALF OF THE APPLICANT. I HAVE PERSONAL KNOWLEDGE OF THE INFORMATION IN THIS APPLICATION AND/OR HAVE EXERCISED DUE DILIGENCE TO CONFIRM THE ACCURACY OF THE INFORMATION IN THIS APPLICATION. I CERTIFY THAT BASED UPON PERSONAL KNOWLEDGE OR UPON INFORMATION AND BELIEF FORMED AFTER REASONABLE INQUIRY, THE STATEMENTS AND INFORMATION CONTAINED IN THIS SUBMITTAL ARE TRUE, ACCURATE, AND COMPLETE.