FILED NOV 09 2011 CHIEF FINANCIAL OFFICER JEFF ATWATER ~ STATE OF FLORIDA D Ocketed by IN THE MATTER OF: CASE NO.: 118323-11-AG WALTER BISCHOFBERGER / WALTER BISCHOFBERGER 275 North Shade Avenue, # 202 Sarasota, FL 34237 ADMINISTRATIVE COMPLAINT You, WALTER BISCHOFBERGER, license I.D. # E049240, are hereby notified that the Chief Financial Officer of the State of Florida has caused to be made an investigation of your activities while licensed as an insurance agent in this state, as a result of which it is alleged: GENERAL ALLEGATIONS 1, Pursuant to Chapter 626, Florida Statutes, you, WALTER BISCHOFBERGER, are currently licensed in this state as a life including variable annuity and health agent. 2. At all times pertinent to the dates and occurrences referred to herein, you, WALTER BISCHOFBERGER, were licensed in this state as a life including variable annuity and health agent. 3. Pursuant to Chapter 626, Florida Statutes, the Florida Department of Financial Services (“Department”) has jurisdiction over your insurance licenses and appointments. Filed February 17, 2012 2:59 PM Division of Administrative Hearings COUNT I 4. The above general allegations are hereby realleged and fully incorporated herein by reference. 5. In or around December of 2009, you, WALTER BISCHOFBERGER, were contacted by S.S. of Bradenton, Florida, who was seeking health insurance, 6. S.S. informed you, WALTER BISCHOFBERGER, of various pre-existing conditions for which she sought coverage. 7. In or about December of 2009, you, WALTER BISCHOFBERGER, for the purpose of receiving a commission, sold to or assisted S.S. in purchasing what you, WALTER BISCHOFBERGER, represented to S.S, would be a health insurance policy to be issued through a health benefit association known as CEO Club Benefits, Inc/AIM Health Plans, Inc. (“CEO/AIM policy”). 8. Between on or about February and June of 2010, S.S. paid approximately $259 a month premiums for the CEO/AIM policy, for which you, WALTER BISCHOFBERGER, received a commission. 9. The CEO/AIM policy purchased by S.S. through you, WALTER BISCHOFBERGER, was not placed with an authorized insurer and was never underwritten by an authorized insurer, 10. You, WALTER BISCHOFBERGER, knew or should have known that the CEO/AIM policy purchased by S.S. through you was not placed with an authorized insurer and was never underwritten by an authorized insurer. 11. You, WALTER BISCHOFBERGER, knew or should have known that the CEO/AIM policy purchased by S.S. through you would not provide the consumer with the health coverage which she specifically sought to obtain. 12. Between February and June of 2010, in addition to monthly premium payments, S.S. incurred approximately $75 in medical bills stemming from a doctor’s visit. This claim was not paid by the CEO/AIM policy, though at least part of it would have been covered if there had been an authorized insurer underwriting the policy. IT IS THEREFORE CHARGED that you, WALTER BISCHOFBERGER, have violated or are accountable under one or more of the following provisions of the Florida Statutes or Florida Administrative Code, which constitute grounds for the suspension or revocation of your licenses as a Florida insurance agent: (a) Section 626.611(7), Florida Statutes, which provides that it is a violation for a licensee 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 to demonstrate lack of reasonably adequate knowledge and technical competence to engage in the transactions authorized by a license or appointment. (c) Section 626.621(2), Florida Statutes, which provides that it is a violation to violate any provision of this code or of any other law applicable to the business of insurance in the course of dealing under the license or appointment. (d) Section 626.621(6), Florida Statutes, which provides in part that it is a violation of law, in the conduct of business under a license or appointment, to engage in unfair methods of competition or in unfair or deceptive acts or practices as prohibited in Part IX of Chapter 626, Florida Statutes or having otherwise shown himself or herself to be a source of injury or loss to the public. (e) Section 626,901(1)(a), Florida Statutes, which provides that it is a violation for any person to, from offices or by personnel or facilities located in this state, or in any other state or country, directly or indirectly act as agent for, or otherwise represent or aid on behalf of another, any insurer not then authorized to transact such insurance in this state in the solicitation, negotiation, procurement, or effectuation of insurance or annuity contracts, or renewals thereof or in any other manner represent or assist such an insurer in the transaction of insurance with respect to subjects of insurance resident, located, or to be performed in this state. (f) Section 626.901(2), Florida Statutes, which provides that if an unauthorized insurer fails to pay in full or in part any claim or loss within the provisions of any insurance contract which is entered into in violation of this section, any person who knew or reasonably should have known that such contract was entered into in violation of this section and who solicited, negotiated, took application for, or effectuated such insurance contract is liable to the insured for the full amount of the claim or loss not paid. (g) Section 626,9521(1), Florida Statutes, which provides that no person shall engage in this state in any trade practice which is defined in Part IX of Chapter 626 as an unfair method of competition or an unfair or deceptive act or practice involving the business of insurance. (h) Section 626.9541(1)(a)1., Florida Statutes, which provides that it is an unfair method of competition or an unfair or deceptive act to knowingly make a statement that misrepresents the benefits, advantages, conditions, or terms of any insurance policy. (i) Section 626.9541(1)(k)1., Florida Statutes, which provides that it is a violation to knowingly make a false or fraudulent written or oral statement on, or relative to, an application or negotiation for an insurance policy for the purpose of obtaining a fee, commission, money, or other benefit from any insurer, agent, broker, or individual. COUNT II 13, The above general allegations are hereby realleged and fully incorporated herein by reference. 14, In or around July of 2009, you, WALTER BISCHOFBERGER, were contacted by C.J. of Lancaster, South Carolina, who was seeking health insurance. 15. C.J, informed you, WALTER BISCHOFBERGER, of his need to obtain health insurance for himself and his spouse. 16. In or around October of 2009, you, WALTER BISCHOFBERGER, for the purpose of receiving a commission, sold to or assisted C.J. in purchasing what you, WALTER BISCHOFBERGER, represented to C.J, would be a health insurance policy to be issued through a health benefit association known as CEO Club Benefits, Inc./AIM Health Plans, Inc. (“CEO/AIM policy”). 17. Between on or about December of 2009 and June of 2010, CJ. paid approximately $403 a month in premiums for the CEO/AIM policy, for which you, WALTER BISCHOFBERGER, received a commission. 18. The CEO/AIM policy purchased by C.J. through you, WALTER BISCHOFBERGER, was not placed with an authorized insurer and was never underwritten by an authorized insurer, 19, You, WALTER BISCHOFBERGER, knew or should have known that the CEO/AIM policy purchased by C.J. through you was not placed with an authorized insurer and was never underwritten by an authorized insurer. 20. You, WALTER BISCHOFBERGER, knew or should have known that the CEO/AIM policy purchased by C.J. through you would not provide the consumer with the health coverage which he specifically sought to obtain. 21, | Between February and June of 2010, in addition to monthly premium payments, C.J. incurred approximately $4,300 in medical bills. These bills were not paid by the CEO/AIM policy, though they would have been at least partly covered if there had been an authorized insurer underwriting the policy. IT IS THEREFORE CHARGED that you, WALTER BISCHOFBERGER, have violated or ate accountable under one or more of the following provisions of the Florida Statutes or Florida Administrative Code, which constitute grounds for the suspension or revocation of your licenses as a Florida insurance agent: (a) Section 626.611(7), Florida Statutes, which provides that it is a violation for a licensee 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 to demonstrate lack of reasonably adequate knowledge and technical competence to engage in the transactions authorized by a license or appointment. (c) Section 626.621(2), Florida Statutes, which provides that it is a violation to violate any provision of this code or of any other law applicable to the business of insurance in the course of dealing under the license or appointment. (d) Section 626.621(6), Florida Statutes, which provides in part that it is a violation of law, in the conduct of business under a license or appointment, to engage in unfair methods of competition or in unfair or deceptive acts or practices as prohibited in Part IX of Chapter 626, Florida Statutes or having otherwise shown himself or herself to be a source of injury or loss to the public. (e) Section 626.901(1)(a), Florida Statutes, which provides that it is a violation for any person to, from offices or by personnel or facilities located in this state, or in any other state or country, directly or indirectly act as agent for, or otherwise represent or aid on behalf of another, any insurer not then authorized to transact such insurance in this state in the solicitation, negotiation, procurement, or effectuation of insurance or annuity contracts, or renewals thereof or in any other manner represent or assist such an insurer in the transaction of insurance with respect to subjects of insurance resident, located, or to be performed in this state. (f) Section 626.901(2), Florida Statutes, which provides that if an unauthorized insurer fails to pay in full or in part any claim or loss within the provisions of any insurance contract which is entered into in violation of this section, any person who knew or reasonably should have known that such contract was entered into in violation of this section and who solicited, negotiated, took application for, or effectuated such insurance contract is liable to the insured for the full amount of the claim or loss not paid. (g) Section 626,9521(1), Florida Statutes, which provides that no person shall engage in this state in any trade practice which is defined in Part IX of Chapter 626 as an unfair method of competition or an unfair or deceptive act or practice involving the business of insurance. (h) —- Section 626.9541(1)(a)l., Florida Statutes, which provides that it is an unfair method of competition or an unfair or deceptive act to knowingly make a statement that misrepresents the benefits, advantages, conditions, or terms of any insurance policy. (i) Section 626.9541(1)(k)1., Florida Statutes, which provides that it is a violation to knowingly make a false or fraudulent written or oral statement on, or relative to, an application or negotiation for an insurance policy for the purpose of obtaining a fee, commission, money, or other benefit from any insurer, agent, broker, or individual. COUNT II 22. The above general allegations are hereby realleged and fully incorporated herein by reference. 23. In October of 2009, you, WALTER BISCHOFBERGER, were contacted by J.T. of Cocoa, Florida, who was seeking health insurance. 24. J.T. informed you, WALTER BISCHOFBERGER, of her need to obtain health insurance for herself and her spouse. 25, In or around October of 2009, you, WALTER BISCHOFBERGER, for the purpose of receiving a commission, sold to or assisted J.T. in purchasing what you, WALTER BISCHOFBERGER, represented to J.T. would be a health insurance policy to be issued through a health benefit association known as CEO Club Benefits, Inc./AIM Health Plans, Inc. (“CEO/AIM policy”). 26. — Starting on or about November of 2009, J.T. paid approximately $501 a month in premiums for the CEO/AIM policy, for which you, WALTER BISCHOFBERGER, received a commission. 27. The CEO/AIM policy purchased by J.T. through you, WALTER BISCHOFBERGER, was not placed with an authorized insurer and was never underwritten by an authorized insurer. 28. You, WALTER BISCHOFBERGER, knew or should have known that the CEO/AIM policy purchased by J.T. through you was not placed with an authorized insurer and was never underwritten by an authorized insurer. 29. You, WALTER BISCHOFBERGER, knew or should have known that the CEO/AIM policy purchased by J.T. through you would not provide the consumer with the health coverage which she specifically sought to obtain. 30. Between February and June of 2010, in addition to monthly premium payments, J.T. incurred approximately $4,450 in medical bills. These bills were not paid by the CEO/AIM policy, though they would have been at least partly covered if there had been an authorized insurer underwriting the policy. IT IS THEREFORE CHARGED that you, WALTER BISCHOFBERGER, have violated or are accountable under one or more of the following provisions of the Florida Statutes or Florida Administrative Code, which constitute grounds for the suspension or revocation of your licenses as a Florida insurance agent: (a) Section 626.611(7), Florida Statutes, which provides that it is a violation for a licensee 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 to demonstrate lack of reasonably adequate knowledge and technical competence to engage in the transactions authorized by a license or appointment. (c) Section 626,.621(2), Florida Statutes, which provides that it is a violation to violate any provision of this code or of any other law applicable to the business of insurance in the course of dealing under the license or appointment. (d) Section 626.621(6), Florida Statutes, which provides in part that it is a violation of law, in the conduct of business under a license or appointment, to engage in unfair methods of competition or in unfair or deceptive acts or practices as prohibited in Part IX of Chapter 626, Florida Statutes or having otherwise shown himself or herself to be a source of injury or loss to the public. (e) Section 626.901(1)(a), Florida Statutes, which provides that it is a violation for any person to, from offices or by personnel or facilities located in this state, or in any other state or country, directly or indirectly act as agent for, or otherwise represent or aid on behalf of another, any insurer not then authorized to transact such insurance in this state in the solicitation, _ negotiation, procurement, or effectuation of insurance or annuity contracts, or renewals thereof or in any other manner represent or assist such an insurer in the transaction of insurance with respect to subjects of insurance resident, located, or to be performed in this state. f) Section 626,901(2), Florida Statutes, which provides that if an unauthorized insurer fails to pay in full or in part any claim or loss within the provisions of any insurance contract which is entered into in violation of this section, any person who knew or reasonably should have known that such contract was entered into in violation of this section and who solicited, negotiated, took application for, or effectuated such insurance contract is liable to the insured for the full amount of the claim or loss not paid. (g) Section 626,9521(1), Florida Statutes, which provides that no person shall engage in this state in any trade practice which is defined in Part IX of Chapter 626 as an unfair method of competition or an unfair or deceptive act or practice involving the business of insurance. (h) Section 626.9541(1)(a)1., Florida Statutes, which provides that it is an unfair method of competition or an unfair or deceptive act to knowingly make a statement that misrepresents the benefits, advantages, conditions, or terms of any insurance policy. qa) Section 626.9541(1)(k)1., Florida Statutes, which provides that it is a violation to knowingly make a false or fraudulent written or oral statement on, or relative to, an application 10 or negotiation for an insurance policy for the purpose of obtaining a fee, commission, money, or other benefit from any insurer, agent, broker, or individual. . COUNT IV 31. The above general allegations are hereby realleged and fully incorporated herein by reference. 32. In October of 2009, you, WALTER BISCHOFBERGER, were contacted by P.M. of Oldsmar, Florida, who was seeking health insurance. 33, P.M. informed you, WALTER BISCHOFBERGER, of her need to obtain health insurance. 34, In or around November of 2009, you, WALTER BISCHOFBERGER, for the purpose of receiving a commission, sold to or assisted P.M. in purchasing what you, WALTER BISCHOFBERGER, represented to P.M. would be a health insurance policy to be issued through a health benefit association known as CEO Club Benefits, Inc./AIM Health Plans, Inc, (“CEO/AIM policy”). 35. Starting on or about November of 2009, P.M. paid approximately $481 a month in premiums for the CEO/AIM policy, for which you, WALTER BISCHOFBERGER, received a commission. 36. The CEO/AIM policy purchased by P.M. through you, WALTER BISCHOFBERGER, was not placed with an authorized insurer and was never underwritten by an authorized insurer. 37. You, WALTER BISCHOFBERGER, knew or should have known that the CEO/AIM policy purchased by P.M. through you was not placed with an authorized insurer and was never underwritten by an authorized insurer. 38, You, WALTER BISCHOFBERGER, knew or should have known that the CEO/AIM policy purchased by P.M. through you would not provide the consumer with the health coverage which she specifically sought to obtain. 39. | While enrolled in the CEO/AIM policy, P.M. incurred approximately $600 in medical bills, These bills were not paid by the CEO/AIM policy, though they would have been at least partly covered if there had been an authorized insurer underwriting the policy. IT IS THEREFORE CHARGED that you, WALTER BISCHOFBERGER, have violated or are accountable under one or more of the following provisions of the Florida Statutes or Florida Administrative Code, which constitute grounds for the suspension or revocation of your licenses as a Florida insurance agent: (a) Section 626.611(7), Florida Statutes, which provides that it is a violation for a licensee 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 to demonstrate lack of reasonably adequate knowledge and technical competence to engage in the transactions authorized by a license or appointment. (c) Section 626,621(2), Florida Statutes, which provides that it is a violation to violate any provision of this code or of any other law applicable to the business of insurance in the course of dealing under the license or appointment. (d) Section 626.621(6), Florida Statutes, which provides in part that it is a violation of law, in the conduct of business under a license or appointment, to engage in unfair methods of competition or in unfair or deceptive acts or practices as prohibited in Part IX of Chapter 626, 12 Florida Statutes or having otherwise shown himself or herself to be a source of injury or loss to the public. (e) Section 626,901(1)(a), Florida Statutes, which provides that it is a violation for any person to, from offices or by personnel or facilities located in this state, or in any other state or country, directly or indirectly act as agent for, or otherwise represent or aid on behalf of another, any insurer not then authorized to transact such insurance in this state in the solicitation, negotiation, procurement, or effectuation of insurance or annuity contracts, or renewals thereof or in any other manner represent or assist such an insurer in the transaction of insurance with respect to subjects of insurance resident, located, or to be performed in this state, (f) Section 626,901(2), Florida Statutes, which provides that if an unauthorized insurer fails to pay in full or in part any claim or loss within the provisions of any insurance contract which is entered into in violation of this section, any person who knew or reasonably should have known that such contract was entered into in violation of this section and who solicited, negotiated, took application for, or effectuated such insurance contract is liable to the insured for the full amount of the claim or loss not paid. (g) Section 626,9521(1), Florida Statutes, which provides that no person shall engage in this state in any trade practice which is defined in Part IX of Chapter 626 as an unfair method of competition or an unfair or deceptive act or practice involving the business of insurance. (h) Section 626.9541(1)(a)1., Florida Statutes, which provides that it is an unfair method of competition or an unfair or deceptive act to knowingly make a statement that misrepresents the benefits, advantages, conditions, or terms of any insurance policy. (i) Section 626.9541(1)(k)1., Florida Statutes, which provides that it is a violation to knowingly make a false or fraudulent written or oral statement on, or relative to, an application 13 or negotiation for an insurance policy for the purpose of obtaining a fee, commission, money, or other benefit from any insurer, agent, broker, or individual. WHEREFORE, you, WALTER BISCHOFBERGER, are hereby notified that the Chief Financial Officer intends to enter an Order suspending or revoking your licenses and appointments as an insurance agent and imposing such penalties as may be provided under the provisions of Sections 626.611, 626.621, 626.681, 626.691, 626.692, 626.901, 626.910, 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 pursuarit 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, DFS 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 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 of the administrative complaint. If a 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 Ca day of iN OVember _, 11. GA TY as. NG f GG / 7 “ ee Greg ; | fe Director, Division of Agent and Agency Services 16 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing ADMINISTRATIVE COMPLAINT has been furnished to: WALTER BISCHOFBERGER, 275 N. Shade Ave. Apt.# 202,, Sarasota, FL 34237, by Certified Mail US. Mail, restricted delivery, this ) day of Novo, by 2011. ek Stramski ssistant General Counsel Fla. Bar. No.: 0087965 Department of Financial Services Division of Legal Services 612 Larson Building 200 East Gaines Street Tallahassee, Florida 32399-0333 (850) 413-4172 17 STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF LEGAL SERVICES IN THE MATTER OF: WALTER BISCHOFBERGER CASE NO.: 118323-11-AG ELECTION OF PROCEEDING I have 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) Lt] 30] 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): {] 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 | 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: Tracey Beal, DFS 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: 12-000691PL