1)Lastyear Sapplication Noteanychangesininformation;And

APPLICATIONFORSECONDYEAROFTWO-YEARTERMOFFUNDEDCONSUMERREPRESENTATIVE

TOCOMPLETESECONDYEAROFTWO-YEARTERMASACONSUMERREPRESENTATIVEATNAICMEETINGSANDTORECEIVEREIMBURSEMENTFOREXPENSESFROMNAIC

FORTHEYEAR2016

Attachacopyof:

1)Lastyear’sapplication–noteanychangesininformation;and

2)Asignedconflictofintereststatement;and

3)Acurrentcopyofyourresume;and

4)Acurrentcopyofyourorganization’sbudget.Pleasecompletethesectionbelowalso.

I.NAME:

II. DEMONSTRATEDEXPERTISEANDEXPERIENCE:

A.ListtheNAICNationalMeetingsandinterimmeetingsyouattendedthispastyear.

B.WhatwasyourprimaryfocusattheNAICthispastyear;i.e.,healthinsurance,lifeinsurance,propertycasualtyinsurance,financialsolvency,marketregulation?

C.Forthearea(s)ofyourprimaryfocus,didyousubmitwrittencommentsorproposalsthispastyear?Ifso,pleaselisttheNAICCommitteesandWorkingGroupstowhichyoumadecomments.

D.Forthearea(s)ofyourprimaryfocus,didyouprovideoralcommentsduringNAICmeetingsthispastyear?Ifso,pleaselisttheNAICCommitteesandWorkingGroupstowhichyoumadecomments.

E. DidyougiveformalpresentationsatanyoftheNAICNationalMeetingsorinterimmeetings?Ifso,pleaselistthemeetingsatwhichyoumadepresentationsandthesubjectmatterorissueforwhichyouconductedresearchandformulatedrecommendations.

F.DidyouparticipateinNAICinterimconferencecalls?Ifso,pleaseprovidetheNAICCommitteeorWorkingGroupnameandestimatethenumberofcalls.

G.WhatinteractionhaveyouhadwiththestateinsurancedepartmentsthispastyearoutsidetheNAICnationalmeetings?

H.Pleaselistanyotheractivitiesthatyoubelievehelpexplainyourcontributionsmadeasan

NAICfundedconsumerrepresentative.

I.Are you interested in participatingin the administrativefunctionsof the Consumer

ParticipationprogrambyservingasamemberoftheBoardofTrustees? Yes No

(ThisopportunityisopenonlytothosewhohaveservedatleastoneyearasanNAICFundedConsumerLiaisonRepresentative.)Boardmembershiprequiresanadditionalcommitmentoftimeandresources,includingparticipationinpersonandintelephonemeetingsaswellasregulare-mailcorrespondence;takingleadershipfororganizingandcommunicatingregardingagendasfortheNAIC/ConsumerLiaisonCommittee,includingsettingtimeschedulesandmeetingsamongtheconsumerrepresentatives,communicatingwithregulators;andcoordinatingwithNAICstaff. Ifyouareinterested,pleasewriteabriefstatementbelowtoexplainyourinterest.Alsopleasenotethatconsumermembersoftheboardareselectedbyregulatormembersoftheboard.

Theinformationcontainedinandsubmittedwiththisapplicationistrueandcompletetothebestofmyknowledge.

SignatureDate

PLEASERETURNTHECOMPLETEDAPPLICATIONTOMEBY5:00P.M.(CENTRAL)ONOCTOBER31,2015.

ELECTRONICSUBMISSIONSAREENCOURAGED.

LoisE.Alexander,CFE,FLMI,HIA,ACP

MarketRegulationManager

NationalAssociationofInsuranceCommissioners

1100WalnutStreet,Suite1500

KansasCity,MO64106

Telephone:(816)783-8517

Facsimile:(816)460-7632

E-Mail:

ADDENDUMTO

CONSUMERREPRESENTATIVEAPPLICATIONCONFLICTOFINTERESTSTATEMENTJULY16,2014

ConsumerrepresentativesappointedbytheNAICareexpectedtoeffectivelyrepresenttheinterestsandviewpointsofconsumers.ConsumerrepresentativesshallnotpurporttorepresenttheviewsoftheNAIC.

Effectiveconsumerrepresentationmaybecompromisediftheconsumerrepresentativereceivedcompensationfromaregulatedentity.

Definition:Forthepurposesofthisdocument,“aregulatedentity”means,“aregulatedentityofstateinsuranceregulators,itstradegroup,orotherentitiesorindividualsactingasagentsorrepresentativesofaregulatedentity.”

Application:AllapplicantsfortheNAICConsumerParticipationprogramareexpectedtocompletetheapplicationfullyandaccurately,includingthequestionaboutindustrycompensationandpotentialconflictsofinterest.TheConsumerBoardofTrusteeswillevaluatetheamountandpurposeoftheindustryexpensereimbursementandcompensation,ifany,anddeterminewhetheritrepresentsaconflictofinterest.

Disclosure:TheconsumerrepresentativemustnotifytheChairoftheConsumerBoardofTrusteesandtheNAICstaffpersonprovidingsupporttotheConsumerBoardofTrusteesif,atanytimeduringanindividual’stermasanNAIC-appointedconsumerrepresentative,aregulatedentityprovidesoragreestoprovidecompensationtotheconsumerrepresentative’sorganization;theconsumerrepresentativeoranimmediatefamilymemberoftheconsumerrepresentative,includingspouse,domesticpartner,parents,siblingsandchildren.Suchnotificationmustoccurbyemailwithinsevendaysofthereceiptofcompensationortheofferofacompensationagreement,whicheverisearlier.

ConflictDetermination:TheConsumerBoardofTrusteeswilldeterminewhetherthecompensationreceivedortheofferofacompensationagreementconstitutesaconflictofinterestbasedondiscussionandestablishedguidelines.

Guidelines:GuidelinestheBoardwilluseinitsevaluationinclude,butarenotlimitedto,thefollowing:

•Expense reimbursement from a regulated entity for actual travel expenses, includingtransportation,lodgingandmeals,generallydoesnotrepresentaconflictifthetravelisrelatedtorepresentationofinsuranceconsumerinterests.Disclosureofsuchexpensereimbursementsisnotrequired.

•Employment income, fees for services provided to regulated entities (eg providing experttestimonyonbehalfofregulatedentitiesevenifcompensationisreceivedfromalawfirm),orothercompensationreceivedfromaregulatedentitymaybeaconflict(unlessitisanexpensereimbursementforactualtravelexpensesfortheconsumerrepresentativeapplicant)andmustbedisclosedtotheboard.

•Receiptofgiftsfromaregulatedentityvaluedatgreaterthan$50.00perappointmentyearoratotalofmorethan$250.00fromallregulatedentitiesintheappointmentyearareconsideredaconflictofinterestandmustbedisclosed.

•Stipendsorhonorariareceivedfromaregulatedentitymaybeaconflictofinterestandmustbedisclosed.

Confidentiality:MembersoftheConsumerBoardofTrusteesmustkeepconfidentialallfinancial,personal,andbusinessinformationsubmittedbytheconsumerrepresentativeapplicant.ConsumerBoardofTrusteediscussionsregardingpotentialconflictswillremainconfidential.ConsistentwithmaintainingtheintegrityoftheConsumerParticipationProgram,onlycontactinformationandconsumerfocus,or,line(s)ofbusinessrepresentedbytheconsumerrepresentativeapplicantwillbemadepublic.

Certification:IcertifythatIhavereceived,readandunderstoodthisNAICConsumerRepresentativeApplicationConflictofInterestStatement.IalsounderstandthatthepurposeofmysignatureonthisStatementistoprotecttheintegrityofthemissionoftheNAIC’sConsumerParticipationPlan.

AsstatedinSection1ofthePlanofOperationsfortheNAICConsumerParticipationProgram,themissionoftheNAICConsumerParticipationProgramistoassisttheNAICinitseffortstosupportstateinsuranceregulationbyprovidingconsumerviewsoninsuranceregulatoryissues.Aqualifiedconsumerorganizationisanational,state,orlocalorganizationthatservestoprotecttheinterestsofconsumersastheyrelatetotheregulationofinsurance.Theirparticipationisbasedontheirdesiretocollectand/orimpartinformationofmutualconcernandinteresttoinsuranceregulatorsandthatrepresentsaconsumerperspective.Onemeasureofwhetheranorganizationrepresentsaconsumerperspectiveisitssourceoffunding.

StatementofUnderstanding:IfurtherunderstandthatifIamappointedbytheNAICConsumerBoardofTrusteestobeaconsumerrepresentativethatIamindicatingbymysignatureonthisformthatIunderstandandagreetoabidebythisStatement.

SignatureofNAICRepresentativeApplicantDate

PrintedNameofNAICRepresentativeApplicant