HomeMy WebLinkAbout2017-06-05-J01V Insurance AgreementM04 Woukee
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AGENDA ITEM:
CITY OF WAUKEE, IOWA
CITY COUNCIL MEETING COMMUNICATION
MEETING DATE: .Tune 5, 2017
AGENDA ITEM: Consideration of approval of a resolution approving State of Iowa— Iowa
Insurance Division Order and Consent to Order in the matter of Two
Rivers Insurance Company Inc.
FORMAT: Consent Agenda
SYNOPSIS INCLUDING PRO & CON: The Iowa Insurance Commissioner has
presented the final Order and Consent to Order in the matter of Two
Rivers Insurance Company, Inc.
FISCAL IMPACT INCLUDING COSTBENEFIT ANALYSIS: City's share of the
settlement agreement is $25,541.47
COMMISSION/BOARD/COMMITTEE COMMENT:
STAFF REVIEW AND COMMENT: Staff would recommend approval of the settlement
agreement and authorize signatures on the release form provided.
RECOMMENDATION: Approve the Resolution
ATTACHMENTS: I. Proposed Resolution
II. State of Iowa Letter
III. Order and Consent to Order
IV. Exhibit A & B ((��
PREPARED BY: Linda Burkhart, Finance Director JC�
THE CITY OF WAUKEE, IOWA
RESOLUTION 17-
APPROVING STATE OF IOWA — IOWA INSURANCE DIVISION ORDER AND
CONSENT TO ORDER IN THE MATTER OF TWO RIVERS INSURANCE COMPANY
INC.
IN THE NAME AND BY THE AUTHORITY OF THE CITY OF WAUKEE, IOWA
WHEREAS, the City of Waukee, Dallas County, State of Iowa, is a duly organized Municipal
Organization; AND,
WHEREAS, the City of Waukee has entered an Iowa Code Chapter 28E agreement with Iowa
Governmental Health Care Plan (IGHCP) to pool risk for health benefits as an insurance
purchasing group for Iowa public employers;AND,
WHEREAS, Two Rivers Insurance Company is the plan administrator of the IGHCP
group;AND,
WHEREAS, the State of Iowa, Iowa Insurance Division has completed an investigation of Two
Rivers Insurance Company Inc and has issued their Order and Consent to Order, Division File
No. 82465; AND,
WHEREAS, the City of Waukee as member of the 28E agreement, is specifically listed in
Exhibit A of the settlement agreement, to receive a portion of the settlement as determined by the
Insurance Commissioner to be $25,541.47.
NOW THEREFORE BE IT RESOLVED by the City Council of the City of Waukee, Iowa on
this 5 h day of June, 2017 that the Order and Consent to Order, including Exhibits A & B, is
hereby approved and accepted by the City of Waukee, and the City Administrator is hereby
authorized to sign Exhibit B, Election to Participate and Release.
William F. Peard, Mayor
Attest:
Rebecca D. Schuett, City Clerk
ROLL CALL VOTE AYE NAY ABSENT ABSTAIN
Anna Bergman
R. Charles Bottenberg
Brian Harrison
Shelly Hughes
Larry R. Lyon
Fields of Opportunities STATE OF IOW A
TERRY E. BRANSTAD
GOVERNOR
KIM REYNOLDS
LT. GOVERNOR
May 22, 2017
Tim Moerman
Waukee City Hall
230 W. Hickman Road
Waukee, Iowa 50263
tmoerman(.@waukee.org
waukee.ora
RE: In the matter of Two Rivers Insurance Company
Case No. 82465
Dear City Administrator Moerman,
DOUG OMMEN
COMMISSIONER OF INSURANCE
VIA CERTIFIED MAIL AND
ELECTRONIC MAIL
The Iowa Insurance Division ("Division") has concluded its investigation into Two Rivers Insurance
Company, Inc. ("Two Rivers") arising from their billing practices for the Iowa Governmental Health Care
Plan ("IGHCP"). The Division and Two Rivers entered into a Consent Order ("Order") on May 22, 2017
after several months of negotiations. A copy of the Order is attached for your reference. The Order is a
matter of public record and is published on the Division's website at https:Hiid.iowa.gov/enforcement-
orders-and-actions.
The Division alleged that Two Rivers developed and charged fees and commissions that were not
disclosed to the members of IGHCP. Specifically, Two Rivers listed an inflated "premium" amount on
annual summaries and monthly billings which consisted of not only the Wellmark established premium
(which already included a 1 or 1.5% commission) but also included undisclosed fees and commissions
charged by Two Rivers. These undisclosed fees and commissions were in addition to the disclosed EBS
billing and partial self -funding fees Two Rivers charged each member and listed on the billing statements.
The Division alleged that these acts are in violation of Iowa Code § 507B.3, which prohibits a person from
engaging in unfair methods of competition, or unfair or deceptive acts or practices, and Iowa Code §
522B.11, which prohibits violations of any insurance law and using dishonest practices or demonstrating
untrustworthiness in the conduct of business in this state. By presenting these fees and commissions as
"premiums," the billing statements and rate summaries had the capacity to mislead the IGHCP members
into believing that this amount was the insurer -established (Wellmark) premium, when it in fact included
undisclosed compensation to Two Rivers.
Impact on Future Two Rivers Billing Practices
As part of the Order, Two Rivers agreed to a cease and desist order that it will not engage in any of the
following acts or practices related to IGHCP:
TWO RUAN CENTER / 601 LOCUST STREET I4'h FLOOR / DES MOINES, IOWA 50309-3738
Telephone 515-281-5705 / Facsimile 515-281-3059 / http://ild,iowa.gov
Adding Two Rivers' compensation to an insurer -established premium and representing such
monetary amount as "premium" on rate summaries or on monthly billings.
2. Failing to separately disclose or itemize Two Rivers' fees or compensation apart from the insurer -
established premium, to the extent they are included, on rate summaries or on monthly billings.
The Order does not prohibit Two Rivers from using an insurer -established premium to structure a partial -
self funding plan, so long as the insurer -established premium, partial self -funding contributions, and any
compensation apart from the insurer -established premium are disclosed as separate line items to the extent
they are included on rate summaries and on monthly billings.
Restitution
Two Rivers is required to pay a sum of $1,314,029.10 to the state of Iowa as restitution to be distributed to
past and current IGHCP members. Member specific restitution amounts were calculated by taking the
total amount of undisclosed fees and commissions charged by Two Rivers to the specific member and
reducing this number to allow for a percentage commission to Two Rivers. We then applied a uniform
percentage to each member's specific undisclosed amount to arrive at individual restitution amounts for
each member. City of Waukee has been apportioned $25,541.47 in restitution.
In order to receive restitution, your entity must agree to and have the designated authorized
representative for your city/school/county sign the Election to Participate and Release, which is
attached as Exhibit B to the Order. Should your entity elect to not sign the Election to Participate and
Release, the funds allotted to your entity will be redistributed to the entities that do elect to participate.
This means that the member specific restitution amount noted in the above paragraph could increase if not
all members elect to participate. We ask that you carefully review the Election to Participate and Release
and share it along with this letter with all required decision makers, such as a board of superintendents,
Mayor, or county attorney, within your entity.
If your entity elects to participate, the signed and completed Election to Participate and Release must be
sent to the attention of the undersigned and received by the Division no later than 4:00 p.m. on August
20, 2017. Please also advise, on separate correspondence, the name of the proper payee and mailing
address for the restitution check that will be issued by the Division subsequent to the closing of the
election period. As with the Order, your decision to participate or not participate will also be subject to
public disclosure.
Please refer to the enclosed example Election to Participate and Release which may provide you with
guidance in completing the form should your entity elect to participate. If you have any questions or
concerns regarding the investigation, Order, or restitution process, please contact Tammi Green at
515.281.4005 ortammi.green@iid.iowa.gov.
Sincerely,
Tammi Green
Enforcement Bureau
Enclosures:
Final Consent Order
Blank Election to Participate and Release
Example Election to Participate and Release
Copy to:
Linda Burkhart
Waukee City Hall
230 W. Hickman Rd.
Waukee, IA 50263
lburl hart r waukee.or
Steve Brick
6701 Westown Parkway
Suite 100
West Des Moines, IA 50266
steve.brick@brickgeiitrylaw.com
Douglas Ommen
Iowa Insurance Commissioner
Johanna Nagel
Compliance Attorney for the Division
Jennifer Lindberg
Compliance Officer
FeLE
MAY 2 2 2017
BEFORE THE IOWA INSURANCE COMMISSIONER I COMMISSION OF
IN THE MATTER OF ) Division File No. 82465
TWO RIVERS INSURANCE COMPANY, INC. ) ORDER AND
NPN 3274643, ) CONSENT TO ORDER
d/b/a Two Rivers Insurance Services, )
and Employee Benefit Systems; )
Respondent. )
NOW THEREFORE, upon motion of the Iowa Insurance Division ("Division") and
consent of Respondent Two Rivers Insurance Company, Inc., pursuant to the provisions of Iowa
Code Chapter 50713—Insurance Trade Practices and Iowa Code Chapter 52213—Licensing of
Insurance Producers, the Commissioner enters the following consent order ("Order'):
I. PARTIES AND JURISDICTION
1. The Commissioner of Insurance, Doug Ommen, administers Iowa Code Chapter 50713—
Insurance Trade Practices and Iowa Code Chapter 522B—Licensing of Insurance Producers
pursuant to Iowa Code § 505.8. The Commissioner has designated staff in the Iowa Insurance
Division to seek enforcement of these provisions. The Division has consented to the entry of this
Order.
2. Two Rivers Insurance Company, Inc. ("Two Rivers") is an Iowa corporation with a home
office of 214 N. Main Street, Burlington, Iowa 52601. Two Rivers does business under several
fictitious names, including, but not limited to "Two Rivers Insurance Services" and "Employee
Benefit Systems." Two Rivers has filed fictitious name registrations with the Iowa Secretary of
State to do business under these names.
3. Two Rivers d/b/a Two Rivers Insurance Services is and has been licensed as a business
entity insurance producer with the Division since October 29, 2010. Two Rivers is licensed under
national producer number 3274643.
4. Two Rivers d/b/a Employee Benefit Systems is and has been licensed as a third party
administrator with the Division since January 21, 2000.
5. The Commissioner of Insurance has jurisdiction over Two Rivers and this matter.
6. The Division has alleged that from January 1, 2005 to on or about May 1, 2014 ("2005
through 2014"), Two Rivers and others engaged in acts or practices constituting cause for
probation, suspension, revocation, fines, orders requiring such persons to cease and desist from
the acts, methods or practices, or other relief under Iowa Code §§ 505.8(10), 50713.3, 507B.4,
507B.6, 507B.7, 52213.11 and 522B.17 and rules adopted pursuant to Iowa Code Chapters 505,
507E and 522B.
7. Two Rivers is aware of its right to notice and a hearing on this matter, the right to be
represented by counsel at a hearing, the right to present evidence and examine witnesses at a
hearing, and the right to appeal from any adverse determination after a hearing. Two Rivers, by
consenting to this Order, knowingly and voluntarily waives these rights, including all rights to
appeal or otherwise contest the validity of this Order.
8. Two Rivers, by its officers and attorneys, knowingly and voluntarily enters into this Order.
Two Rivers denies the allegations found herein and denies that it has engaged in any unlawful acts
or practices.
II. STIPULATIONS OF FACT
9. In 2005, several public entities organized the Iowa Governmental Health Care Plan
("IGHCP") under Iowa Code Chapter 28E. IGHCP was an agreement to pool risk for health and
other welfare benefits as an insurance purchasing group of Iowa public employers.
10. Through the efforts of Two Rivers and others, Wellmark, Inc. began writing health
insurance coverage for IGHCP from its inception. Wellmark, Inc. ("Wellmark") is a mutual
insurance company that was incorporated under the laws of the state of Iowa on September 14,
1939. Wellmark is authorized by the insurance commissioner to issue individual and group health
insurance. Wellmark's group health insurance plans are governed by various insurance laws
including Iowa Code Chapter 509.
III. DIVISION'S ALLEGATIONS
11. Wellmark is required by Iowa Code § 432.1 to report to the state of Iowa gross premiums
received during the preceding calendar year in order to determine premium tax liability. Wellmark
filed premium tax returns for each of the years of 2005 through 2014, annually reporting gross
direct written premium.
12. In establishing premiums for IGHCP, Wellmark established an initial premium for each
member through the use of actuarial standards.
13. On an annual basis thereafter, Wellmark established premium rates for IGHCP for each
renewal plan year from 2006 through 2014. A plan year for IGHCP ran from July 1 of any given
year to June 30 of the subsequent year.
14. To facilitate the IGHCP yearly insurance renewals, Two Rivers received up to twenty plans
from Wellmark each year. Two Rivers then structured approximately three times as many plans
with various levels of self -funding dependent upon the needs of each IGHCP member.
15. From the years 2005 through 2013, Mutual Med Insurance Services, LLC ("Mutual Med")
was the wholesale agency for Wellmark. Wellmark required Two Rivers to operate through a
wholesaler to receive Wellmark plans. Wellmark's premiums included commission of 1%. For
the time period of 2005 through approximately July 2013, Two Rivers did not receive any portion
of the commission paid to Mutual Med. In approximately July 2013, Mutual Med negotiated an
increase in the commission percentage and forwarded .25% of its commission to Two Rivers.
Mutual Med was terminated by Wellmark as the wholesale agency effective approximately
October 1, 2013 and Two Rivers then received all of the commission that previously went to
Mutual Med until approximately March 2014. Two Rivers held, in a separate ledger account, both
the .25% received from Mutual Med and the full commission received after Mutual Med's
termination pending advice.
16. Two Rivers added compensation, whether described internally as ` EBS billing fee" or
"Commission to Two Rivers," to Wellmark's premium rates for each member of the IGHCP for
each plan year from 2005 until April 2014.
17. During the years of 2005 through 2014 Two Rivers's compensation was totaled with
Wellmark rates and then presented to each member of IGHCP on rate summaries on an annual
basis and on monthly billings in various ways as premium (e.g. "insurance company premium,"
"medical premium," or "IGHCP Premium"). Two Rivers did not separately itemize or disclose its
fees and/or commissions in the materials provided to IGHCP members.
COUNT I
Iowa Code § 507B.3
18. Iowa Code § 50713.3 provides:
A person shall not engage in this state in any trade practice which is defined in this
chapter as, or determined pursuant to section 50713.6 to be, an unfair method of
competition, or an unfair or deceptive act or practice in the business of insurance.
19. Iowa Code § 50713.6 provides:
Whenever the commissioner believes that any person has been engaged or is
engagingin this state in anyunfairmethod of competition or any unfair or deceptive
act or practice whether or not defined in section 50713.4, 507B.4A, or 50713.5 and
that a proceeding by the commissioner in respect to such method of competition or
unfair or deceptive act or practice would be in the public interest, the commissioner
shall issue and serve upon such person a statement of the charges in that respect
and a notice of a hearing on such charges to be held at a time and place fixed in the
notice, which shall not be less than ten days after the date of the service of such
notice.
20. Iowa Code § 507B.7(1) provides that upon determining that a person has engaged in an
unfair method of competition or an unfair or deceptive act or practice, the Commissioner shall
order the person to cease desist and may order a civil penalty not to exceed ten thousand dollars,
unless the person knew or should have known that they were in violation of this subtitle, in which
case the penalty may not exceed fifty thousand dollars in any six-month period.
21. Iowa Code § 505.8(10) provides:
The commissioner may, after a hearing conducted pursuant to chapter 17A, assess
fines or penalties; assess costs of an examination, investigation, or proceeding;
order restitution; or take other corrective, action as the commissioner deems
necessary and appropriate to accomplish compliance with the laws of the state
relating to all insurance business transacted in the state.
22. The Division has alleged that during the period of 2005 through 2014, Two Rivers engaged
in unfair and deceptive acts and practices in violation of Iowa Code § 50713.3 by presenting various
monetary amounts as "premium" on rate summaries provided on an annual basis and on monthly
billings to each of the members of IGHCP that, in fact, included Wellmark premium rates plus
Two Rivers' compensation and that such representations had the capacity to mislead members into
believing the presented amounts were entirely premium established by Wellmark and concealed
the amounts of Two Rivers' compensation.
23. Violations of Iowa Code § 50713.3 and applicable rules as alleged would constitute grounds
for the imposition of a civil penalty, an order of restitution, and an order requiring such person to
cease and desist from the unfair and deceptive acts, methods or practices pursuant to Iowa Code
§§ 50713.6 and 50713.7.
COUNT II
Iowa Code § 522B.11
24. Iowa Code § 522B.I 1(1) provides:
The commissioner may place on probation, suspend, revoke, or refuse to issue or
renew an insurance producer's license or may levy a civil penalty as provided in
section 522B.17 for any one or more of the following causes:
b. Violating any insurance laws, or violating any regulation, subpoena, or order of
the commissioner or of a commissioner of another state.
h. Using fraudulent, coercive, or dishonest practices, or demonstrating
incompetence, untrustworthiness, or financial irresponsibility in the conduct of
business in this state or elsewhere.
25. Iowa Code § 522B.17(1) provides:
An insurer or insurance producer who, after hearing, is found to have violated this
chapter may be ordered to cease and desist from engaging in the conduct resulting
in the violation and may be assessed a civil penalty pursuant to chapter 507B.
26. The Division has alleged that during the period of 2005 through 2014, Two Rivers violated
Iowa Code §§ 522B.11(1)(b) and (h) in the conduct of business in this state by adding
compensation to the Wellmark premiums and presenting the increased dollar amounts to members
of IGHCP as "premium."
27. Violations of Iowa Code § 522B.I1(1) and applicable rules as alleged would constitute
grounds for revocation, suspension, censure, the imposition of a civil penalty, an order of
restitution, and an order requiring such person to cease and desist from the unfair and deceptive
acts, methods or practices pursuant to Iowa Code §§ 522B.11, 522B.17, 50713.6 and 50713.7.
IV. AGREED CEASE AND DESIST ORDER
Two Rivers, consents to entry of a voluntary cease and desist order and, prior to the entry
of this Order, changed the practices at issue in this Order by disclosing the amount of the
Wellmark-established premiums and by entering into consulting agreements with members of
IGHCP in order to charge and disclose fees for Two Rivers' services.
NOW THEREFORE, IT IS ORDERED that Two Rivers Insurance Company, Inc., and
its officers, directors, agents and representatives, shall not engage in any act or practice in violation
of Iowa Code § § 50713.3 and 50713.6 and shall not engage in the following practices:
A. Adding Two Rivers' compensation to an insurer -established premium and representing
such monetary amount as `premium" on rate summaries or on monthly billings provided
to members of IGHCP, or using any similar representations or formats that have a capacity
to mislead members into believing the represented amounts are entirely premium
established by the insurer; and
B. Failing to separately disclose or itemize Two Rivers' fees or other compensation, apart
from the insurer -established premium, to the extent they are included on rate summaries or
on monthly billings provided to members of IGHCP.
This Order does not prohibit Two Rivers from using an insurer -established premium to
structure partial self -funding plans so long as the insurer -established premium; any partial self -
funding contributions; and any commissions, fees or other compensation apart from the insurer -
established premium are disclosed as separate line items to the extent they are included on rate
summaries and on monthly billings.
V. RESTITUTION
IT IS FURTHER ORDERED that Two Rivers Insurance Company, Inc. shall pay
contemporaneous with its consent to this order the amount of $1,314,029.10 to the state of Iowa
to the credit of the Settlement Fund of the Iowa Insurance Division, as restitution to be distributed
to past and current IGHCP members in accordance with the allocations in Exhibit A, attached and
incorporated herein.
As a condition of receiving the allocated restitution, the IGHCP member must agree to sign
the Election to Participate and Release which is attached as Exhibit B and incorporated herein by
reference. If the IGHCP member does not sign the Election to Participate and Release, the
allocated restitution sum will be distributed amongst the participating members. The Division will
notify the IGHCP members of this within thirty (30) days of the issuance of this Order. IGHCP
members will have sixty (60) days following the notification period to return the signed Election
to Participate and Release to the Division.
VI. RIGHT TO REOPEN
IT IS FURTHER ORDERED that the Division's agreement to, and the Commissioner's
issuance of, this Order, is expressly premised upon the truthfulness, accuracy, and completeness
of the Two Rivers's representations concerning its ability to pay a financial penalty, including a
restitution amount. If, upon motion by the Division, the Commissioner finds that Two Rivers
failed to disclose material assets, misrepresented the value of any asset, or made other material
misrepresentations or omissions, this matter may be reopened for the purpose of assessing
additional restitution amounts and civil penalties.
VII. RELEASE
IT IS FURTHER ORDERED that upon finalization of this Order and payment of the
required funds, the Division, and the Commissioner, acknowledge that this .Order releases the
Respondent, Two Rivers Insurance Company, Inc., its: current and former board members,
directors, officers, employees, with the express exception of Kerry Erts, Scott Saveraid, and.Kevin
Carr, from liability for any additional civil or administrative penalties or actions by the
Commissioner, the Division, or the staff of the Division in connection with Two Rivers's billing
practices relating to fees, commissions, or other compensation charged to groups organized under
28B agreements and any conduct and violations of Iowa insurance laws as described in this Order.
Upon finalization of this Order and payment of the required funds, the Division and the
Commissioner, acknowledge that this Order releases Two Rivers Financial Group, Two Rivers
Bank & Trust, and Two Rivers's successors from liability for any additional civil or administrative
penalties or actions by the Commissioner, the Division, or the staff of the Division in connection
with Two Rivers's billing practices relating to fees, commissions, or other compensation charged
to groups organized under 28E agreements and any conduct and violations of Iowa insurance laws
as described in this Order.
This Order does not release Respondent from civil or criminal liabilities, if any, that may
be asserted by any other governmental entity.
SO ORDERED on this day of YYr_ c,. �, 2017.
DO"^UGLGGLL-ASS M. OMMEN
Iowa Insurance Commissioner
Respectfully submitted,
JOHANN59NAGL
Compliance Attorney
Iowa Insurance Division
Two Ruan Center
601 Locust Street, 4"' Floor
Des Moines, to 50309
johannanagel@iid.iowa.gov
515.725.1255
Attorney for the Iowa Insurance Division
Copies to:
Michael Richards
Davis Brown Law Firm
215 100' Street, Suite 1300
Des Moines, IA 50309
Susan Freed
Davis Brown Law Firm
215 10th Street, Suite 1300
Des Moines, IA 50309
Sarah Crane
Davis Brown Law Firm
215 10'h Street, Suite 1300
Des Moines, IA 50309
Attorneys for Respondent
CONSENT TO ORDER AND AGREEMENT
�Gu-f414ljas president and on behalf of Two Rivers Insurance Company,
Inc., Respondent in this matter, have read, understood, and do knowingly consent to this Order in
its entirety. By executing this consent, I understand that Two Rivers Insurance Company, Inc, is
waiving its rights to a hearing, to confront and cross-examine witnesses, to produce evidence, and
to judicial review.
I further understand that this Order is considered final administrative action that may be
reported by the Division to the National Association of Insurance Commissioners and to other
regulatory agencies. I also understand that this Order is a public record under Iowa Code Chapter
22 that will be disclosed to other state regulatory authorities, upon request, pursuant to Iowa Code
section 505.8(8)(d). I also understand that the Order will be posted to the Division's web site and
a notation will be made to the publicly available web site record that administrative action has
been taken against me.
Z/
Dated this 15 day of emu_ 12017.
TWO RIVERS INSURANCE PANY, INC.
By
Subscribed and sworn before me on this day of�, 2017.
Notary Public for the State of Iowa
L,Ovp HEATHER MARIE HOWELL
FC M mission Number 804730
My C'mmissbn Ezplres April 2a 2020
EXHIBIT A
Central Lee (w/PSF)
$ 41,023.73
Chickasaw Co.
1,876.72
City of Clive
32,856.94
City of Council Bluffs
253,428.10
City of Fairfield
28,315.60
City of Grinnell
3,273.67
City of Harlan
21,321.00
City of Keokuk
53,247.26
City of Pella
25,835.43
City of Perry
8,878.00
City of Spencer
20,330.70
City of Waukee
25,541.47
City of Waverly
1,981.12
City of Webster City
9,823.98
Clay County
35,480.28
Clayton County
35,670.11
Council Bluffs Public Library
8,201.95
Council Bluffs Waterworks
24,511.65
Dubuque County
11,894.56
Emmet County
21,094.58
Grundy County
52,322.10
Guthrie County
21,551.95
Hancock County
50,994.04
Henry County
63,502.99
Hurnboldt County
43,395.22
Jefferson County
37,586.91
Keokuk CSD
135,315.05
Monona County
18,725.22
Pottawattamie County
143,356.02
Seymour CSD
18,374.12
Spencer CSD
50,551.36
Union County
8,054.57
Winnebago County
5,712.71
Total $ 1,314,029.10
NOTE: The above -reference amounts are subject to change with the amounts going up should a listed
member decline to participate.
EXHIBIT B
ELECTION TO PARTICIPATE AND RELEASE
I, as (position) and on behalf of
_(entity name) elect to participate in the distribution of the restitution amount
ordered pursuant to the consent order ("Order") entered into by the Iowa Insurance Division and
Two Rivers Insurance Company, Inc., on
2017 regarding matter number 82465.
By executing this election and receiving a payment for restitution, (entity)
agrees to release Two Rivers Insurance Company, Inc., its current and former board members,
directors, officers, employees, with the express exception of Kerry Erts, Scott Saveraid, and Kevin
Can, from liability for any civil claims or penalties in connection with Two Rivers's conduct as
described in the Order. (entity) further agrees to release Two Rivers Financial
Group, Two Rivers Bank & Trust, and Two Rivers Insurance Company, Inc.'s successors from
liability for any civil claims or penalties in connection with Two Rivers's conduct as described in
the Order.
Dated this _ day of , 2017.
(ENTITY NAME)
By (*)
Subscribed and sworn before me on this _ day of
2017.
Notary Public for the State of lows