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

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).

Reviewed by: