California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 6.5 - Financial Examinations of Derivative Transactions › Article 1 - Conflicts of Interest › Section 2690.94 - Conflict of Interest and Disclosure of Affiliation Form

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
COMPANY (COMPANIES) _______________
Examination Period ____________________
Investment Consultant: _______________
1. Does the Investment Consultant have a
				  written policy to define conflicts of interest and a process in place to check
				  for and detect actual or potential conflicts of interest?
If yes, please describe the process in
					 detail:
2. Does the
				  Investment Consultant, or any employee of the Investment Consultant who is
				  assigned to the examination of the COMPANY, have a direct or indirect
				  investment in the COMPANY, or did the Investment Consultant or any employee of
				  Investment Consultant assigned to the examination of the COMPANY have a direct
				  or indirect investment in the COMPANY within the last 12 months or during the
				  period of time for which the examination will apply?
If yes, please explain:
3. Does the Investment Consultant have a
				  direct or indirect affiliation with the COMPANY, or did the Investment
				  Consultant have a direct or indirect affiliation with the COMPANY within the
				  last 12 months or during the period of time for which the examination will
				  apply?
If yes, please explain:
4. Has the Investment Consultant, or any
				  employee of the Investment Consultant who is assigned to the examination of the
				  COMPANY, performed any services and/or received any income from the COMPANY
				  within the last 12 months or during the period of time for which the
				  examination will apply?
If yes, please explain:
5. Does the Investment Consultant, or any
				  employee of the Investment Consultant who is assigned to the examination of the
				  COMPANY, hold any current position with the COMPANY, or has the Investment
				  Consultant, or any employee of the Investment Consultant who is assigned to the
				  examination of the COMPANY, held any position with the COMPANY within the last
				  12 months or during the period of time for which the examination will apply?
If yes, please explain:
6. Does the Investment Consultant, or any
				  employee of the Investment Consultant who is assigned to the examination of the
				  COMPANY, have any financial relationship with the COMPANY, or did the
				  Investment Consultant, or any employee of the Investment Consultant assigned to
				  the examination of the COMPANY, have any financial relationship with the
				  Company within the last 12 months or during the period of time for which the
				  examination will apply?
If yes, please explain:
7. Has the Investment Consultant, or any
				  employee of the Investment Consultant who is assigned to the examination of the
				  COMPANY, received any gifts, compensation, services, or any other thing of
				  monetary value from the COMPANY within the last 12 months or during the period
				  of time for which the examination will apply?
If yes, please list the items and explain:
8. Was the Investment Consultant, or any
				  employee of the Investment Consultant who is assigned to the examination of the
				  COMPANY, involved in any way with the investments that are the subject of this
				  examination?
If yes, please explain:
9. Does the Investment Consultant have any
				  potential engagements or contracts that are currently being considered which
				  would result in an affirmative response to any of the questions above?
If yes, please explain.
Circle one attestation clause as appropriate:
I have used all reasonable diligence in preparing this
					 statement. I have reviewed this statement and to the best of my knowledge the
					 information contained herein is true and complete.
OR
I _________________________ (name of Officer), hereby
					 represent and warrant that I am authorized to complete this Conflict of
					 Interest and Disclosure of Affiliation Form on behalf of _______________ (name
					 of company). I do so in my capacity as ____________________ (title of
					 Officer).
___________________________
___________________________
Investment Consultant
Date
Reviewed by:
___________________________
___________________________
Department of Insurance
Date
1. New
					 section filed 12-19-2006; operative 1-18-2007 (Register 2006, No.
					 51).
Note: Authority cited: Section
						1211(l),
						Insurance Code. Reference: Section
						1211,
						Insurance Code; and California Code of Regulations, Title 2, Chapter 7,
						Sections 18703.1 and
						18703.4.