N.Y. Comp. Codes R. & Regs. tit. 11, § 29.6 – Exhibit.

(a) The form in subdivision (b) of this section is hereby approved for use as specified in this Part.
(b) Governmental Insurance Disclosure Statement.
Governmental Insurance Disclosure Statement
Pursuant to 11 NYCRR 29.5 (Insurance Regulation 87), the undersigned hereby affirms, under the penalties of perjury, that the statements made hereinafter are true.
Filed by: Name:
Address:
1. Name of governmental unit that ordered insurance services and/or coverages:
2. Name and office address, including county, of person who placed the order for insurance services or coverages:
3. Will you share any fees or commissions received on account of business listed in item 1 with any other licensee(s) or other person(s), directly or indirectly?
Yes □ No □
4. Are you a public officer or party officer?
Yes □ No □
If you answered NO to items 3 and 4 you are not required to answer items 5 through 10. You must sign and date the form where indicated and mail it to the address indicated below.
If you answered YES to items 3 or 4 you are required to complete the remaining applicable items and you must sign and date the form where indicated and mail it to the address indicated below.
5. Names and addresses of licensees or others to whom you paid fees and/or commissions:
6. The dollar amount you paid to each licensee or other person:
7. The services rendered by the persons listed in item 5, for which a share of commissions was paid:
8. Schedule of coverages placed on account of which fees or commissions were paid to the persons listed in item 5:
Name of Insurer Policy Number
9. Services rendered on account, of which fees were paid to the persons listed in item 5.
10. What public office or party office do you hold?
Date: __________ Signature
Type name of person whose
signature appears above:
Telephone No.:__________
Mail the original disclosure statement to:
New York State Department of Financial Services
Licensing Bureau
One Commerce Plaza - 20th Floor
Albany, NY 12257
Mail a copy of the disclosure statement to the most senior official of the governmental unit who ordered the insurance services or coverages listed thereon.