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HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-9/19/2006 MtERlTAS. ~ GROUP Group Insurance Department The Dental and Eye Care Experts~ P.O. Box 81889 / Lincoln, NE 68501-1889 59000 Street / Lincoln, NE 68510-2234 Bus: 402-467-1122 A Division of Ameritas Life Insurance Corp. A UNIFI Company September 19, 2006 City of Colleyville Attn: City Secretary 100 Main Street Colleyville, Texas 76034 RE: Conflict of Interest Disclosure Dear City Secretary: Texas law requires any person or business that is considering doing business or that contracts with a local governmental entity file a "Conflict of Interest Questionnaire". Our records indicate that Ameritas Life Insurance Corp. has recently submitted a proposal to become the insurer for the dental and/or eye care coverage for the City of Colleyville. Enclosed is a completed Conflict of Interest Disclosure document for your records. If you have any questions, please feel free to contact me at 1-800-659-2223, ext. 82222, or, email Q mckeownla>.ameritas. com. Sincerely, ~~,'~I~ ~cKeown, ACS Manager, Group Compliance Enclosure CONFLICT OF INTEREST QUESTIONNAIRE For vendor or other person doing business with local governmental entity FORM CIQ This questionnaire is being filed in accordance with chapter 176 of the Local Government Code by a person doing business with the governmental entity. By law this questionnaire must be filed with the records administrator of the local government not later than the 7th business day after the date the person becomes aware of facts that require the statement to be filed. See Section 176.006, Local Government Code. OFFICE USE ONLY A person commits an offense if the person violates Section 176.006, Local Government Code. An offense under this section is a Class C misdemeanor. n~.~ O~M'''~'' "'}[]: @ ~ n\V7 ~ ~ D ~2";___~~ ~ S E F 2 a 2006 U ~I LI CITY SECRETARY'S OFFICE ~ Name of person doing business with local governmental entity. Ameritas Life Insurance Corp. ~ D Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than September 1 of the year for which an activity described in Section 176.006(a), Local Government Code, is pending and not later than the 7th business day after the date the originally filed questionnaire becomes incomplete or inaccurate.) ~ Describe each affiliation or business relationship with an employee or contractor of the local governmental entity who makes recommendations to a local government officer of the local governmental entity with respect to expenditure of money. Ameritas Life Insurance Corp. has a business relationship with Brinson Benefits who may have a business relationship with the local governmental entity. IiJ Describe each affiliation or business relationship with a person who is a local government officer and who appoints or employs a local government officer of the local governmental entity that is the subject of this questionnaire. None Amended 01113/2006 CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ Page 2 For vendor or other person doing business with local governmental entity 5 Name of local government officer with whom filer has affiliation or business relationship. (Complete this section only ifthe answer to A, B, or C is YES.) This section, item 5 including subparts A, B, C & D, must be completed for each officer with whom the filer has affiliation or business relationship. Attach additional pages to this Form CIQ as necessary. A. Is the local government officer named in this section receiving or likely to receive taxable income from the filer of the questionnaire? DYes DNO B. Is the filer of the questionnaire receiving or likely to receive taxable income from or at the direction of the local government officer named in this section AND the taxable income is not from the local governmental entity? DYes DNO C. Is the filer of this questionnaire affiliated with a corporation or other business entity that the local government officer serves as an officer or director, or holds an ownership of 10 percent or more? DYes DNO D. Describe each affiliation or business relationship. 6 Describe any other affiliation or business relationship that might cause a conflict of interest. None 7 .- (1-\q-o~ itl1 the governmental entity Date Amended 01/13/2006