Application for Registration as a

Service Contract Provider

To be legally registered as a Service Contract Provider in Washington State, please provide the following information. Your application will be reviewed promptly against Washington requirements.

Before completing the application, please note the following:

IMPORTANT

This application is intended only for use by service contract providers who are contractually obligated (“obligors”) to the contract holder under the terms of the service contract. Chapter 48.110 RCW does not provide for registration of administrators. Failure to meet the legal definition as a service contract provider as defined under RCW 48.110.020(20) is grounds for revocation of this registration, if issued. Only the registrant has authority under a registration. This registration cannot be used for wholesale purposes.

An altered application form will be considered invalid.

OTHER

For a copy of Chapter 48.110 RCW, access at: Chapter 48.110 RCW.

RCW 48.110.030(1) precludes any operation or activity as a service contract provider until it is registered. Do not issue any service contracts, solicit, or accept any applications until you receive a Registration. If you intend to issue vehicle service contracts, you must also have your service contract forms pre-approved by our Rates and Forms Division. Proposed forms may be submitted for approval following completion of your registration. Penalties for non-compliance can be severe.

Applications are processed on a “first in, first out” basis.

The non-refundable application fee is $250, payable to “The Office of the Insurance Commissioner”.

All information contained within your submission, such as this, is considered a matter of public record. Marking any material as “Private” or “Confidential” does not preclude its availability or its status as a public document. See our website for more information about public records.

ONCE REGISTERED

All material changes to the information contained in this application, including the registrant’s financial condition, shall be disclosed to this Office within 30 days after the end of the month in which the change occurred – RCW 48.110.030(6).

Application is hereby made for issuance of a Registration as a

Service Contract Provider in the State of Washington.

I. Service Contract Provider Basic Information
1. List the exact legal name of the Service Contract Provider.
2. List any other names under which the Service Contract Provider is or may be doing business in this State or any other State if different than above.
3. Provide complete domicile address where legally formed
4. Provide complete physical address of operations and where records are maintained
5. Provide complete mailing address (if different than #3 or #4) and the name, phone, and email for the person who will be responsible for maintenance of this registration.
6. Give the nine-digit Federal Tax Identification Number (FEIN) for the applicant.
7. Provide the name, phone, and email for the person who is the contact for follow up on this application.
8. The applicant will issue the following type of service contracts to residents of Washington: Note: the applicant is responsible for applying for the correct registration. Please review applicable laws to be sure you have applied for the correct registration: RCW 48.110.017, and RCW 48.110.020: Definitions. Failure to register correctly is grounds for revocation of a registration. Check all lines that you are applying for:
Vehicle (mechanical breakdown only):	IF CLAIMING EXEMPTIONS UNDER RCW 48.110.902 Vehicle (mechanical breakdown only):
Non-Vehicle: Type of Personal Property under contract (explain):	Manufacturer or Wholly-owned subsidiary of: ------------------------------------- Import Distributor or Wholly-owned subsidiary of:
Other: Tire & Wheel Paintless Dent Removal Motor Vehicle windshield chip/crack repair/replacement Motor Vehicle key or key fob replacement	Note: Under RCW 48.110.902, these contracts are “motor vehicle service contracts” as of 6/9/16, which forms must be filed per RCW 48.110.073(3). Tire & Wheel Paintless Dent Removal Motor Vehicle windshield chip/crack repair/replacement Motor Vehicle key or key fob replacement
Residential Utilities: Water Sewer Other (explain):

II. Required Documentation
Attach all other documents and items, necessary* for this application. The referenced items need to be attached in the order presented below. Use the check box to indicate that the information is enclosed within the submission. *If the applicant qualifies for exemption under RCW 48.110.902, certain items are not required.
9. Applicant Profile
A. Legal Formation Documents (such as Articles of Incorporation, LLC Certificate) Include all amendments B. Internal Governance Documents (such as current By-Laws, Operating Agreement) C. A current Certificate of Good Standing from the Washington Secretary of State as a foreign registered entity D. A current Certificate of Good Standing from the domiciliary Secretary of State E. A completed Service of Process designation F. A complete organization chart showing all affiliates of the applicant and percentage of ownership of every company in the chart. G. A list of names, addresses, and official positions, of each director and officer of the applicant. For each individual listed, attach a completed Biographical Affidavit. Use the prescribed Form 11 available through the NAIC Website. H. A listing of all significant shareholders or owners, including percentage of ownership. If more than 50% of the applicant’s gross revenue is derived from the sale of service contracts, include any person or entity owning or having the right to acquire 10% or more of the voting securities of the applicant. For each individual listed, attach a completed Biographical Affidavit. Use the prescribed Form 11 available through NAIC Website. I. The name, address, and direct contact information (telephone and email) of the designated compliance officer responsible for ensuring compliance with this Chapter, should a registration be issued. Required Financial Ability and Indemnification J. A copy of the applicant’s financial statements that prove the company is solvent or meets the minimum net worth requirement as follows: Option 1: If relying on a reimbursement insurance policy per RCW 48.110.050(2)(a) or RCW 48.110.075(2)(a) - (Note: This requirement is specific to the applicant. Any submissions that do not show the financial position of the applicant on a stand-alone basis will not be accepted): The most recent audited annual financial statements; or If a start-up, provide the most recent audited financial statements; or Provide the most recent annual financial statements certified as accurate by two (or more) officers of the applicant; or If a start-up, provide the most recent financial statements that are certified as accurate by two (or more) officers of the applicant. (Note: the Commissioner’s prescribed form for certifications of the financial statements must be used. An altered or incomplete form will be considered invalid.) Option 2: If relying on a reserve and trust under RCW 48.110.050(2)(b) - (Note: this requirement is specific to the applicant. Any submissions that do not show the financial position of the applicant on a stand-alone basis will not be accepted). The most recent audited annual financial statements; or If a start-up, provide the most recent audited financial statements Option 3a: If the applicant is relying on maintaining a minimum net worth or stockholder equity of $100 Million per RCW 48.110.050(2)(c) – (Note this requirement is specific to the applicant. Any submissions that do not show the financial position of the applicant on a stand-alone basis will not be accepted). The applicant’s most recent audited annual financial statements; or If a start-up, provide the applicant’s most recent audited financial statements; or Provide the most recent Form 10-K or Form 20-F filed with the SEC Option 3b: If relying on its parent to maintain a minimum net worth or stockholder equity of $100 Million per RCW 48.110.050(2)(c: (First certify) I certify that the applicant is solvent and will maintain a solvent financial condition. If found insolvent by the OIC, I understand that RCW 48.110.130 authorizes the Commissioner to deny, suspend, or revoke the registration. (Then, check one) The parent’s most recent audited annual financial statements; or If a start-up, provide the parent’s most recent audited financial statements; or Provide the parent’s most recent Form 10-K or Form 20-F filed with the SEC K. Identification of the method by which the applicant intends to assure the faithful performance of its obligations under its service contracts. Note: Check only one option. Option 1: A reimbursement insurance policy issued by a qualified (as outlined in statute) insurer or risk retention group (RRG). a) The applicant must request a complete copy of the policy along with the certificate of coverage be direct-issued to the OIC from the insurer or RRG stating that the submitted policy is: 1) in-force; 2) complete; 3) compliant with RCW 48.110.060; and 4) compliant with all form and rate filing requirements under Chapters 48.18 and 48.19 RCW. Provide the name of the insurer/RRG, and c) WAOIC# as licensed/registered. Note: if the applicant will be issuing vehicle service contracts it must use this option and consolidate all types of service contracts under one policy. The direct-issued policy must be received within 45 days of receipt of the application. Option 2: Maintain a funded reserve account and place a deposit with the Commissioner. Note: For applicants who will be issuing only non-vehicle and other service contracts who want to use a surety bond, the bond form is available on our website. Option 3: Applicant or parent company maintain a net worth of at least $100 Million. (Note: For applicants who will be issuing only non-vehicle and other service contracts - if using the parent company’s net worth, attach the original prescribed Parental Agreement & Guarantee form required under RCW 48.110.050(2)(c)(ii). An altered or incomplete form will be considered invalid).

III. Service Contract Provider (SCP) Statements of Understanding
Please acknowledge assent to each of the following items. By “wet” initialing each box, the applicant specifically agrees:
10. The SCP understands that the commissioner may conduct investigations as deemed necessary to determine whether any person has violated any provision of this Chapter. (RCW 48.110.120)
11. The SCP understands that it is required to maintain detailed books and records of all Washington transactions to which this Chapter applies. (RCW 48.110.090)
12. The SCP understands that it must conduct all business in its own legal name. (RCW 48.110.080(2))
13. The SCP understands and will abide by provisions of this Chapter. It agrees that any failure to adhere to the statutory requirements constitutes grounds for disciplinary action, including suspension, revocation, or non-renewal of the registration.
14. The SCP understands that it must provide timely notification of any material change to its registration information, including its financial condition. (RCW 48.110.030(6))
15. The SCP has included the application fee of $250 within this submission, and understands that the fee is non-refundable regardless of the disposition of the application.
16. The SCP understands that all contracts must be fully compliant with all applicable RCWs and WACs.
17. The SCP is the contractual obligor and liable to the contract holder under this registration and understands that, if issued, the registration applies only to the registrant and no other entity, i.e.; natural or corporate persons, affiliates, agents, assignees, contractors, marketers, representatives, etc.

IV. Service Contract Provider General Interrogatories
Answer “yes” or “no” to each of the following items. Note: If the answer is yes to any item below, attach information and copies of documentation for each item and each individual.
18. Are there any formal or informal regulatory actions, pending or which have been taken, against the applicant by any governmental agency?
19. Are there any formal or informal regulatory actions, pending or which have been taken, against any officers, directors, trustees, partners, or members of the applicant by any governmental agency?
20. Have the applicant or any of its officers, directors, trustees, partners or members been convicted of any criminal or civil offenses (other than minor traffic violations)?
21. Are there any pending criminal or civil actions (other than minor traffic violations) against the applicant or any of its officers, directors, trustees, partners or members?
22. Have the applicant or any unregistered affiliate, solicited or issued service contracts to residents of Washington prior to application? If answering “Yes”, in your documentation, the following minimal information is required: 1) If an affiliate, identify the entity in its legal name and any dba’s or private labels used; 2) the number of contracts sold per year by contract type; 3) the total remuneration received by type of contract per year; 4) the number of existing contracts; 5) the date on which all contracts will expire; 6) the date on which all unauthorized activity began; and 7) the date on which all unauthorized activity ceased.
23. Has the applicant: Sold, transferred, or encumbered any portion of its assets or business, or directly or indirectly pledged its outstanding capital stock? Merged or consolidated with any other company within the last 2 years? Presently in negotiation for or inviting negotiations for any transaction described above?

Certification: With knowledge of the penalties for false statements, I certify that the undersigned, duly authorized to make this application on behalf of the applicant, hereby swears and affirms that the foregoing statements and information regarding the applicant, and the contents of all attachments, are true and correct*.

_____________________________

Signature

Typed Name

Typed Title

State of )

County of	)

Sworn before me this day of , 20 .

_________________________________________________

Notary Public - My Commission Expires:

*In addition to penalties for perjury, RCW 48.110.130 authorizes the Commissioner to deny, suspend, or revoke the registration of a service contract provider if the Commissioner finds that the service contract provider made a material misstatement in its application for registration; or has obtained or attempted to obtain a registration through misrepresentation or fraud.

STATE OF WASHINGTON

OFFICE OF THE INSURANCE COMMISSIONER

APPOINTMENT OF ATTORNEY TO ACCEPT SERVICE

Provider Legal Name:

Home Office Address:

City, State, Zip: OIC#:

The Service Contract Provider (called the Provider) is duly organized under the laws of the State of . The Provider hereby appoints the Insurance Commissioner of the State of Washington, and any successor in office, as its lawful attorney to receive service of all legal process issued against it in the state of Washington upon causes of action arising within the state of Washington. Service upon the Commissioner as attorney constitutes service upon the Provider.

In accordance with RCW 48.110.030(3)(a), the Provider designates the following natural or corporate Person to whom the Commissioner must forward legal process so served on him or her:

Legal Name:

Email Address:

Street Address:

City, State, Zip:

In accordance with RCW 48.110.030(3)(b), the appointment of the Insurance Commissioner of the State of Washington as attorney is irrevocable, binds any successor in interest or to the assets or liabilities of the Provider, and remains in effect for as long as there could be any cause of action against the Provider arising out of any of the Provider’s contracts or obligations in this state.

Effective July 22, 2011, any service of process will be accomplished and processed in accordance with RCW 48.02.200. This designation will remain in place until the Provider files a new designation.

I acknowledge that I am authorized to execute and am executing this document on behalf of the Provider.

IN WITNESS OF THIS APPOINTMENT, the Provider has caused this instrument to be executed in its name by the undersigned at the City of , in the State of ,this day of , 20 .

By: ________________________________________

Printed Name:

Title: