NOV 16 201 : CHIEF FINANCIAL OFFICER TEA edb locKeled Dy IN THE MATTER OF: EEE a PATRICA RILEY CASE NO. 120081-11-AG ADMINISTRATIVE COMPLAINT. TO: Patricia Riley c/o Denise V. Powers, Esq 2600 Douglas Road, Ste. 607 Coral Gables, FL 33134 You, PATRICIA RILEY, are hereby notified that pursuant to Chapter 626, Florida Statutes, the Chief Financial Officer of the State of Florida, has caused to be made an investigation of your activities while licensed as a public adjuster in this state, as a result of which it is alleged: GENERAL ALLEGATIONS 1. You, PATRICIA RILEY, are currently licensed in the state as a public adjuster (3- 20). The original issue date for your license was December 4, 2008. 2. Atall times pertinent to the dates and occurrences referred to in this Administrative Complaint you, PATRICIA RILEY, were licensed as a public adjuster in this state. 3. Atall times pertinent to the dates and occurrences referred to in this Administrative Complaint you, PATRICIA RILEY, failed to appoint a primary adjuster, pursuant to Section 626.8697(4), Florida Statutes. Filed January 25, 2012 9:41 AM Division of Administrative Hearings ) y 4, Atall times pertinent to the dates and occurrences referred to in this Administrative Complaint you, PATRICIA RILEY, were the registered agent, as well as all officers, for Florida Public Consultants, Inc., a business incorporated under the laws of the state of Florida, and located at 270 NW 183" St., Miami FL 33169. 5. Pursuant to Chapter 626, Florida Statutes, the Chief Financial Officer of the State of Florida and the Department of Financial Services has jurisdiction over your insurance license and your eligibility for licensure and appointment. 6. Chapter 69B-220.201, Florida Administrative Code, provides that the work of adjusting insurance claims engages the public trust, in which an adjuster shall put the duty for fair and honest treatment of the claimant above the adjuster’s own interests in every instance; by adjusting all claims strictly in accordance with the insurance contract, by providing truthful and unbiased reports of the facts after making a complete investigation, by handling every adjustment and settlement with honesty and integrity, and allowing a fair adjustment or settlement to all parties without any remuneration to him or herself except that to which he or she is legally entitled. A breach of any provision of this rule constitutes an unfair claims settlement practice. The consumers described in this Administrative Complaint trusted you, PATRICIA RILEY, and you abused that trust. COUNT I 7. The above General Allegations numbered one through six are hereby realleged and fully incorporated herein by reference. 8. Atall times pertinent to the dates and occurrences referred to in this Administrative Complaint, you, PATRICIA RILEY, disseminated through internet website(s), business cards, and/or paper flyers, images that featured a photograph of you holding a telephone to your ear with 2 the words “Call Patricia Today”, and a telephone number. In addition to a list of the types of claims you claimed to handle, the advertisements contained the words “Many Years of Experience” and/or “A Name You Can Trust.” 9. By willfully omitting your full name on the advertisements, you PATRICIA RILEY, violated Florida Statutes and Department Rules. 10. By advertising that you, PATRICIA RILEY, had “many years of experience” when in fact you had been licensed only a few months, your advertisements deceived consumers who relied on your advertisements and contacted you for business as a public adjuster. IT IS THEREFORE CHARGED that you, PATRICIA RILEY, have violated or are accountable under the following provisions of the Florida Insurance Code which constitute grounds for the suspension or revocation of your licenses as an insurance agent in the state: (a) Section 626.611(7), Florida Statutes, which provides that it is a violation for any applicant, agent, title agency, adjuster, customer representative, service representative, or managing general agent to demonstrate a lack of fitness or trustworthiness to engage in the business of insurance. (b) Section 626.611(8), Florida Statutes, which provides that it is a violation for any applicant, agent, title agency, adjuster, customer representative, service representative, or managing general agent to demonstrate a lack of reasonably adequate knowledge and technical competence to engage in the transactions authorized by license or appointment. (c) Rule 69B-220.501(4)(c), Florida Administrative Code, which provides that any advertisement by a public adjuster shall state the full name as specified in department records of the public adjuster who has caused the advertisement to appear. (d) Sections 626.854(8), and 626.9541, Florida Statutes, which provides that it is a deceptive and unfair insurance trade practice for a public adjuster to disseminate any advertisement, announcement, or statement containing any assertion, representation, or statement with respect to the business of insurance which is untrue, deceptive, or misleading; including, but not limited to, any statement or representation that invites an insured policyholder to submit a claim by stating that there is “no risk” to the policyholder by submitting such claim. (ec) Section 626.8697(2)(h)2., Florida Statutes, which provides that it is a violation for a public adjuster to demonstrate a lack of fitness or trustworthiness to engage in the business of insurance adjusting arising out of activities related to insurance adjusting or the adjusting firm, with such a frequency as to have made the operation of the adjusting firm hazardous to the insurance- buying public or other persons. (f) Section 626.8698(6), Florida Statutes, which provides that it is a violation for a public adjuster to violate any ethical rule of the department. (g) Section 626.9541(1)(b), Florida Statutes, which provides that it is an unfair method of competition and an unfair or deceptive act or practice, violative of Section 626.9521, Florida Statutes, to knowingly make, publish, disseminate, circulate, or place before the public, or cause, directly or indirectly, to make, publish, disseminate, circulate, or place before the public in a newspaper, magazine, or other publication, or in the form of a notice, circular, pamphlet, letter or poster, or over any radio or television station, or in any other way, an advertisement, announcement, or statement containing any assertion, representation, or statement with respect to the business of insurance, which is untrue, deceptive, or misleading. COUNT II 11, The above General Allegations numbered one through six are hereby realleged and fully incorporated herein by reference. 12. On or around April 1, 2009, consumer V.J., 82 years of age, signed a contract to hire you, PATRICIA RILEY, and your company Florida Public Consultants, Inc. (FPCD, to represent the consumer’s interests before First Home Insurance Company, regarding a claim for property damage caused by faulty plumbing. 13. Contrary to Florida Statutes, the contract provided by you, PATRICIA RILEY, fails to include the full name of the public adjuster, fails to state the percentage of compensation for the public adjuster’s services, and fails to include the statement against fraud, as required by Section 626.8796, Florida Statutes. 14, Contrary to Florida Statutes and ethical standards for public adjusters, you, PATRICIA RILEY, negotiated a fee agreement guaranteeing you thirty-three percent of the gross settlement amount. 15. Contrary to Florida Statutes and ethical standards for public adjusters, you, PATRICIA RILEY, after acquiring the consumer’s trust and confidence, presented a sheaf of papers for V.J. to sign and date, which she did without reading their content. As a result, and unbeknownst to the consumer, V.J., she also hired Encore Services Inc, a construction company with ties to you, PATRICIA RILEY, to perform all of the construction/remodeling work. 16. You, PATRICIA RILEY, failed to provide V.J. with any opportunity to investigate the qualifications of ENCORE SERVICES INC., or any of the contractors you presented to V.J. on a list that she signed and dated that day. 17. You, PATRICIA RILEY, failed to provide V.J. with a written estimate of the repairs prior to commencement of the repair work, some of which was completed that day, April 1, 2009. IT IS THEREFORE CHARGED that you, PATRICIA RILEY, have violated or are accountable under the following provisions of the Florida Insurance Code which constitute grounds for the suspension or revocation of your licenses as an insurance agent in the state: (a) Section 626.611(7), Florida Statutes, which provides that it is a violation for any applicant, agent, title agency, adjuster, customer representative, service representative, or managing general agent to demonstrate a lack of fitness or trustworthiness to engage in the business of insurance, (b) Section 626.611(9), Florida Statutes, which provides that it is a violation for any applicant, agent, title agency, adjuster, customer representative, service representative, or managing general agent to exhibit fraudulent or dishonest practices in the conduct of business under the license or appointment. (c) Section 626.611(10), Florida Statutes, which provides that it is a violation for any applicant, agent, title agency, adjuster, customer representative, service representative, or managing general agent to misappropriate, convert, or unlawfully withhold moneys belonging to insurers or insureds or beneficiaries or to others and received in conduct of business under the license. Section 626.854(11), Florida Statutes, which provides that it is a violation for any public adjuster to charge fees in excess of the limits provided in statute. (d) Sections 626.854(8), and 626.9541, Florida Statutes, which provides that it is a ' deceptive and unfair insurance trade practice for a public adjuster to disseminate any advertisement, announcement, or statement containing any assertion, representation, or statement ) ») with respect to the business of insurance which is untrue, deceptive, or misleading; including, but not limited to, any statement or representation that invites an insured policyholder to submit a claim by stating that there is “no risk” to the policyholder by submitting such claim. (ec) Section 626.8697(2)(i), Florida Statutes, which provides that it is a violation for a public adjuster to fail to appoint a primary adjuster. (f) Section 626.8697(2)(h)1., Florida Statutes, which provides that it is a violation for a public adjuster to misappropriate, convert, or unlawfully or unreasonably withhold moneys belonging to insurers or insureds or beneficiaries or claimants or to others and received in the conduct of business under the license, with such a frequency as to have made the operation of the adjusting firm hazardous to the insurance-buying public or other persons. (g) Section 626.8697(2)(h)2., Florida Statutes, which provides that it is a violation for a public adjuster to demonstrate a lack of fitness or trustworthiness to engage in the business of insurance adjusting arising out of activities related to insurance adjusting or the adjusting firm, with such a frequency as to have made the operation of the adjusting firm hazardous to the insurance- buying public or other persons. (h) Section 626.8698(6), Florida Statutes, which provides that it is a violation for a public adjuster to violate any ethical rule of the department. @) Rule 69B-220.201(3)(b)2., Florida Administrative Code, which provides that an adjuster shall adjust all claims strictly in accordance with the insurance contract. Gj) Rule 69B-220.051(6), Florida Administrative Code, which provides the required contract terms necessary for every public adjuster contract. (k) Rule 69B-220.201(3)(a), Florida Administrative Code, which provides than an adjuster shall not directly or indirectly refer or steer any claimant needing repairs or other services in 7 J J) connection with a loss to any person with whom the adjuster has an undisclosed financial interest, or who will or is reasonably anticipated to provide the adjuster any direct or indirect compensation for the referral or for any resulting business. (1) Rule 69B-220.201(3)(h), Florida Administrative Code, which provides that an adjuster shall exercise extraordinary care when dealing with elderly clients to assure that they are not disadvantaged in their claims transactions by failing memory or impaired cognitive processes. (m) Rule 69B-220.201(3)(n), Florida Administrative Code, which provides that an adjuster shall not draft special releases called for by the unusual circumstances of any settlement or otherwise draft any form of release, unless advance written approval by the insurer can be demonstrated to the Department. (n) Rule 69B-220.201(3)(0), Florida Administrative Code, which provides that an adjuster not undertake the adjustment of any claim concerning which the adjuster is not currently competent and knowledgeable as to the terms and conditions of the insurance coverage, or which otherwise exceeds the adjuster’s current expertise. (0) Rule 69B-220.201(4)(b), Florida Administrative Code, which provides that an adjuster shall notify the insured or claimant in advance of the name and location of any proposed contractor, architect, engineer, or similar professional, before any bid or proposal by any of these persons may be used by the public adjuster in estimating the loss or negotiating settlement, The insured or claimant may exercise veto power of any of these persons, in which case that person shall not be used in estimating costs. (p) Rule 69B-220.201(4)(c), Florida Administrative Code, which provides that the public adjuster shall ensure that if a contractor, architect, engineer, or other professional is used in yd. ) formulating estimates or otherwise participates in the adjustment of the claim, the professional shall be licensed by the Florida Department of Business and Professional Regulation. (q) Section 626.9541(1)(b), Florida Statutes, which provides that it is an unfair method of competition and an unfair or deceptive act or practice, violative of Section 626.9521, Florida Statutes, to knowingly make, publish, disseminate, circulate, or place before the public, or cause, directly or indirectly, to make, publish, disseminate, circulate, or place before the public in a newspaper, magazine, or other publication, or in the form of a notice, circular, pamphlet, letter or poster, or over any radio or television station, or in any other way, an advertisement, announcement, or statement containing any assertion, representation, or statement with respect to the business of insurance, which is untrue, deceptive, or misleading. COUNT III 18, The above General Allegations numbered one through six are hereby realleged and fully incorporated herein by reference. 19. ‘On or around May 5, 2009, consumer M.H. signed a contract to hire you, PATRICIA RILEY, to represent the consumer’s interests before Florida Peninsula Insurance Company, regarding a claim for property damage caused by faulty plumbing. 20. Contrary to Florida Statutes, the contract provided by you, PATRICIA RILEY, fails to include the full name of the public adjuster, fails to state the percentage of compensation for the public adjuster’s services, and fails to include the statement against fraud, as required by Section 626.8796, Florida Statutes. IT IS THEREFORE CHARGED that you, PATRICIA RILEY, have violated or are accountable under the following provisions of the Florida Insurance Code which constitute grounds for the suspension or revocation of your licenses as an insurance agent in the state: 9 ) ) (a) Section 626.611(7), Florida Statutes, which provides that it is a violation for any agent to demonstrate a lack of fitness or trustworthiness to engage in the business of insurance. (b) Sections 626.854(8), and 626.9541, Florida Statutes, which provides that it is a deceptive and unfair insurance trade practice for a public adjuster to disseminate any advertisement, announcement, or statement containing any assertion, representation, or statement with respect to the business of insurance which is untrue, deceptive, or misleading. (c) Section 626.8697(2)(i), Florida Statutes, which provides that it is a violation for a public adjuster to fail to appoint a primary adjuster. (d) Section 626.8698(6), Florida Statutes, which provides that it is a violation for a public adjuster to violate any ethical rule of the department. (e) Rule 69B-220.201(4)(), Florida Administrative Code, which provides that a public adjuster shall ensure that all contracts for the public adjuster’s services are in writing and set forth all terms and conditions of the engagement, including the terms required by subsection 69B- 220.051(6), F.A.C. (f) Rule 69B-220.051(6), Florida Administrative Code, which provides that public adjusters shall ensure that all contracts for their services contain the following terms: the full name, in a legible manner, as specified in Department records of the public adjuster signing the contract; the public adjuster’s permanent business address and phone number; the public adjuster’s Florida Department license number; the insured’s full name and street address; the address of loss; a brief description of the loss; the insured’s insurance company name and policy number, if available; the date the contract with the public adjuster was actually signed by the insured or claimant; the full compensation to the public adjuster; and any costs to be reimbursed to the public adjuster out of the proceeds shall be specified in an addendum to the contract. 10 COUNT IV 21. The above General Allegations numbered one through nine are hereby realleged and fully incorporated herein by reference. 22. On or around April 30, 2009, consumer A.M. signed a contract to hire you, PATRICIA RILEY, to represent the consumer’s interests before Florida Peninsula Insurance Company, regarding a claim for property damage caused by faulty plumbing. 23. Contrary to Florida Statutes, the contract provided by you, PATRICIA RILEY, fails to include the full name of the public adjuster, fails to state the percentage of compensation for the public adjuster’s services, and fails to include the statement against fraud, as required by Section 626.8796, Florida Statutes, IT IS THEREFORE CHARGED that you, PATRICIA RILEY, have violated or are accountable under the following provisions of the Florida Insurance Code which constitute grounds for the suspension or revocation of your licenses as an insurance agent in the state: (a) Section 626.611(7), Florida Statutes, which provides that it is a violation for any agent to demonstrate a lack of fitness or trustworthiness to engage in the business of insurance. (b) Sections 626.854(8), and 626.9541, Florida Statutes, which provides that it is a deceptive and unfair insurance trade practice for a public adjuster to disseminate any advertisement, announcement, or statement containing any assertion, representation, or statement with respect to the business of insurance which is untrue, deceptive, or misleading. (c) Section 626.8697(2)(i), Florida Statutes, which provides that it is a violation for a public adjuster to fail to appoint a primary adjuster. (d) Section 626.8698(6), Florida Statutes, which provides that it is a violation for a public adjuster to violate any ethical rule of the department. 11 ) ) (e) Rule 69B-220.201(4)G), Florida Administrative Code, which provides that a public adjuster shall ensure that all contracts for the public adjuster’s services are in writing and set forth all terms and conditions of the engagement, including the terms required by subsection 69B- 220.051(6), F.A.C. (f) Rule 69B-220.051(6), Florida Administrative Code, which provides that public adjusters shall ensure that all contracts for their services contain the following terms: the full name, in a legible manner, as specified in Department records of the public adjuster signing the contract; the public adjuster’s permanent business address and phone number; the public adjuster’s Florida Department license number; the insured’s full name and street address; the address of loss; a brief description of the loss; the insured’s insurance company name and policy number, if available; the date the contract with the public adjuster was actually signed by the insured or claimant; the full compensation to the public adjuster; and any costs to be reimbursed to the public adjuster out of the proceeds shall be specified in an addendum to the contract. COUNT V 24. The above General Allegations numbered one through nine are hereby realleged and fully incorporated herein by reference. 25. On or around August 2, 2009, consumer D.T. signed a contract to hire you, PATRICIA ° RILEY, to represent the consumer’s interests before Gulfstream Property Insurance Company, regarding a claim for property damage caused by faulty plumbing. 26. Contrary to Florida Statutes, the contract provided by you, PATRICIA RILEY, fails to include the full name of the public adjuster, fails to state the percentage of compensation for the public adjuster’s services, and fails to include the statement against fraud, as required by Section 626.8796, Florida Statutes. 12 ) ) IT IS THEREFORE CHARGED that you, PATRICIA RILEY, have violated or are accountable under the following provisions of the Florida Insurance Code which constitute grounds for the suspension or revocation of your licenses as an insurance agent in the state: (a) Section 626.611(7), Florida Statutes, which provides that it is a violation for any agent to demonstrate a lack of fitness or trustworthiness to engage in the business of insurance. (b) Sections 626.854(8), and 626.9541, Florida Statutes, which provides that it is a deceptive and unfair insurance trade practice for a public adjuster to disseminate any advertisement, announcement, or statement containing any assertion, representation, or statement with respect to the business of insurance which is untrue, deceptive, or misleading. (c) Section 626.8697(2)(i), Florida Statutes, which provides that it is a violation for a public adjuster to fail to appoint a primary adjuster. (d) Section 626.8698(6), Florida Statutes, which provides that it is a violation for a public adjuster to violate any ethical rule of the department. (e) Rule 69B-220.201(4)(i), Florida Administrative Code, which provides that a public adjuster shall ensure that all contracts for the public adjuster’s services are in writing and set forth all terms and conditions of the engagement, including the terms required by subsection 69B- 220.051(6), F.A.C. (f) Rule 69B-220.051(6), Florida Administrative Code, which provides that public adjusters shall ensure that all contracts for their services contain the following terms: the full name, in a legible manner, as specified in Department records of the public adjuster signing the contract; the public adjuster’s permanent business address and phone number; the public adjuster’s Florida Department license number; the insured’s full name and street address; the address of loss; a brief description of the loss; the insured’s insurance company name and policy number, if available; the 13 » +) date the contract with the public adjuster was actually signed by the insured or claimant; the full compensation to the public adjuster; and any costs to be reimbursed to the public adjuster out of the proceeds shall be specified in an addendum to the contract. WHEREFORE, you, PATRICIA RILEY, are hereby notified that the Chief Financial Officer intends to enter an Order suspending or revoking your licenses, appointments and your eligibility for licensure as an insurance agent in this state or to impose such penalties as may be provided under the provisions of Sections 626.611, 626.621, 626.681, 626.691, 626.692, and 626.9521, Florida Statutes, and under the other referenced sections of the Florida Statutes as set out in this Administrative Complaint. NOTICE OF RIGHTS You have the right to request a proceeding to contest this action by the Department of Financial Services ("Department") pursuant to Sections 120.569 and 120.57, Florida Statutes, and Rule 28-106, Florida Administrative Code. The proceeding request must be in writing, signed by you, and must be filed with the Department within twenty-one (21) days of your receipt of this notice. Completion of the attached Election of Proceeding form and/or a petition for administrative hearing will suffice as a written request. The request must be filed with Julie Jones, Agency Clerk, at the Florida Department of Financial Services, 612 Larson Building, 200 East Gaines Street, Tallahassee, Florida 32399-0390. Your written response must be received by the Department no later than 5:00 p.m. on the twenty-first day after your receipt of this notice. Mailing the response on the twenty-first day will not preserve your right to a hearing. YOUR FAILURE TO RESPOND IN WRITING WITHIN TWENTY-ONE (21) DAYS OF YOUR RECEIPT OF THIS NOTICE WILL CONSTITUTE A WAIVER OF YOUR RIGHT TO REQUEST A PROCEEDING ON THE MATTERS ALLEGED HEREIN AND AN ORDER OF SUSPENSION OR REVOCATION WILL BE ENTERED AGAINST YOU. 14 d ) If you request a proceeding, you must provide information that complies with the requirements of Rule 28-106.2015, Florida Administrative Code. As noted above, completion of the attached Election of Proceeding form conforms to these requirements. Specifically, your response must contain: . (a) The name, address, and telephone number, and facsimile number (if any) of the respondent (for the purpose of requesting a hearing in this matter, you are the "respondent"). (b) The name, address, telephone number, facsimile number of the attorney or qualified representative of the respondent (if any) upon whom service of pleadings and other papers shall be made. (c) A statement requesting an administrative hearing identifying those material facts that are in dispute. If there are none, the petition must so indicate. (d) A statement of when the respondent received notice of the administrative complaint. (e) A statement including the file number to the administrative complaint. Ifa hearing of any type is requested, you have the right to be represented by counsel or other qualified representative at your expense, to present evidence and argument, to call and cross-examine witnesses, and to compel the attendance of witnesses and the production of documents by subpoena. If a proceeding is requested and there is no dispute of material fact, the provisions of Section 120.57(2), Florida Statutes, apply. In this regard, you may submit oral or written evidence in opposition to the action taken by the Department or a written statement challenging the grounds upon which the Department has relied. While a hearing is normally not required in 15 ) ») the absence of a dispute of fact, if you feel that a hearing is necessary, one will be conducted in Tallahassee, Florida, or by telephonic conference call upon your request. However, if you dispute material facts which are the basis for the Department’s action, you must request an adversarial proceeding pursuant to Sections 120.569 and 120.57(1), Florida Statutes. These proceedings are held before a State Administrative Law Judge of the Division of Administrative Hearings. Unless the majority of witnesses are located elsewhere, the Department will request that the hearing be conducted in Tallahassee, Florida. Failure to follow the procedure outlined with regard to your response to this notice may result in the request being denied. All prior oral communication or correspondence in this matter shall be considered freeform agency action, and no such oral communication or correspondence shall operate as a valid request for an administrative proceeding. Any request for an administrative proceeding received prior to the date of this notice shall be deemed abandoned unless timely renewed in compliance with the guidelines as set out above. Mediation of this matter pursuant to Section 120.573, Florida Statutes, is not available. No Department attorney will discuss this matter with you until the response has been received by the Department. DATED and SIGNED this eae day of KIOVE Moe _, 2011. ww is Director of Agent & Agency Services 16 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing Administrative Complaint and the following ELECTION OF PROCEEDING has been furnished by U.S. Certified Mail to PATRICIA RILEY, c/o Denise V. Powers, Esq., at 2600 Douglas Road, Ste. 607, Coral Gables, FL 33134, and at 270 NW 183" Street, Suite A, Miami, Florida, 33369 on this (gth day of Reeamoee 2011, Chael A. Kliner Division of Legal Services 612 Larson Building Tallahassee, FL 32399-0333 Tel: (850) 413-4300 Attorney for the Department Fla. Bar No. 909350 ) ) STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF LEGAL SERVICES IN THE MATTER OF: PATRICIA RILEY CASE NO. 120081-11-AG ELECTION OF PROCEEDING Ihave received and have read the Administrative Complaint filed by the Florida Department of Financial Services ("Department") against me, including the Notice of Rights contained therein, and I understand my options. I am requesting disposition of this matter‘as indicated below. (CHOOSE ONE) 1] 3.0) I do not dispute any of the Department’s factual allegations and I do not desire a hearing. I understand that by waiving my right to a hearing, the Department may enter a final order that adopts the Administrative Complaint and imposes the sanctions sought, including suspending or revoking my licenses and appointments as may be appropriate. I do not dispute any of the Department's factual allegations and I hereby elect a proceeding to be conducted in accordance with Section 120.57(2), Florida Statutes. In this regard, I desire to (CHOOSE ONE): C1 Submit a written statement and documentary evidence in lieu of a hearing; or [] Personally attend a hearing conducted by a department hearing officer in Tallahassee; or [J Attend that same hearing by way of a telephone conference call. I do dispute one or more of the Department's factual allegations. I hereby request a hearing pursuant to Section 120.57(1), Florida Statutes, to be held before the Division of Administrative Hearings. I have attached to this election form the information required by Rule 28-106.2015, Florida Administrative Code, as specified in subparagraph (c) of the Notice of Rights, Specifically, I have identified the disputed issues of material fact. TO PRESERVE YOUR RIGHT TO A HEARING, YOU MUST FILE YOUR RESPONSE WITH THE DEPARTMENT OF FINANCIAL SERVICES WITHIN TWENTY-ONE (21) DAYS OF YOUR RECEIPT OF THE ADMINISTRATIVE COMPLAINT. THE RESPONSE MUST BE RECEIVED BY THE DEPARTMENT NO LATER THAN 5:00 P.M. ON THE TWENTY-FIRST DAY AFTER YOUR RECEIPT OF THE ADMINISTRATIVE COMPLAINT, The address for filing is: Julie Jones, Agency Clerk, Florida Department of Financial Services, 612 Larson Building, 200 East Gaines Street, Tallahassee, Florida 32399-0390, Signature Print Name Date: Address: Date Administrative Complaint Received: If you are represented by an attorney or qualified Phone No.: representative, please attach to this election form his or her name, address, telephone and fax numbers Fax No.: 18

Docket for Case No: 12-000405PL