NAME: _________________________ HMO: ____________________________

This is to certify that, except as described below, neither I nor, to my knowledge, any members of my family (including relatives by marriage) have or will:

1. engage, directly or indirectly, in any transaction for the purchase or sale of securities, materials or other property, or services by or to the HMO, otherwise than in the normal capacity of performing duties for the HMO; or
2. be an office, director, trustee, partner or employee of or consultant to any person, corporation, partnership or other organization which, to my knowledge, will engage in any transaction with the HMO or is engaged in a business in competition with the HMO; or
3. be interested monetarily, directly or indirectly, in any person or organization described in paragraph (2) above; or
4. be a recipient, directly or indirectly, of any payments or loans or gifts of any kind (other than reasonable travel expense and entertainment necessary as a normal part of business activity) or any free services, discounts or other favors from or on behalf of any person or organization described in paragraph (2) above (unless by way of dividends); or
5. engage, directly or indirectly, in disclosure of confidential HMO information for the personal benefit or advantage of any person; or
6. engage, directly or indirectly, in any other activity which could be questioned on the ground of conflict of interest.

Any exceptions to (1), (2), (3), (4), (5), (6) above are stated below, with a full description of the transactions and of the interest, whether direct or indirect, which I or any member of my immediate family had in the person or organization having such transactions or competing with the HMO:

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

The Division of Insurance must be notified in writing of any changes inn your status as reported above during your employment with the HMO.

Please state and describe your job position with the HMO company: ____________________________________________________

___________________________________________________________________________________________________________

State your salary and any other compensation you will receive from the HMO or any of its affiliates:___________________________

(If additional space is needed to complete any of the above, please continue on reverse side and initial.)

Date_______________________ __________________________________________________

Signature

(Rev. 2/05)