ITN 16-0001 ATTACHMENT C CITIZENS PROPERTY INSURANCE CORPORATION VENDOR CONFLICT OF INTEREST DISCLOSURE FORM This form is required for all contracts or individual purchases with a total value of $35,000 or more Vendors are responsible for disclosing a current or reasonably foreseeable conflict of interest involving Citizens is required by law and corporate policy to avoid, neutralize, Citizens (a “Necessary Disclosure”). or mitigate significant potential or actual organizational conflicts of interest. Respond to each disclosure statement in the boxes below. In completing the disclosure statements: a Necessary Disclosure exists or if you are uncertain whether a particular You should select “Yes” if circumstance constitutes a Necessary Disclosure and, in either event, explain the circumstances. You should select if you know that a Necessary Disclosure does not exist. “No” You should select and not reasonably if it is unduly burdensome to “None known ascertainable” discover the correct response for reasons such as your workforce is so large that it is unreasonable to ascertain whether any Necessary Disclosures exist, and you in fact do not have knowledge of any Necessary Disclosure. Disclosure Statement 1: Employment by Vendor of a current Citizens employee or Board Member, or Relative of a current Citizens employee or Board Member. Check One: ☐ ☐ ☐ Yes No None known and not reasonably ascertainable. If you answered Yes, please explain: If you known and not reasonably please state reason why the answer is not answered “None ascertainable,” reasonably ascertainable: Disclosure Statement 2: Employment by Vendor of a former Citizens Senior Manager or Board Member, or Relative of a former Citizens Senior Manager or Board Member. Check One: ☐ ☐ ☐ Yes No None known and not reasonably ascertainable. If you answered Yes, please explain: If you answered known and not reasonably please state reason why the answer is not “None ascertainable,” reasonably ascertainable:
ITN 16-0001 ATTACHMENT C CITIZENS PROPERTY INSURANCE CORPORATION VENDOR CONFLICT OF INTEREST DISCLOSURE FORM This form is required for all contracts or individual purchases with a total value of $35,000 or more Vendors are responsible for disclosing a current or reasonably foreseeable conflict of interest involving Citizens (a “Necessary Disclosure”). Citizens is required by law and corporate policy to avoid, neutralize, or mitigate significant potential or actual organizational conflicts of interest. Respond to each disclosure statement in the boxes below. In completing the disclosure statements: You should select “Yes” if a Necessary Disclosure exists or if you are uncertain whether a particular circumstance constitutes a Necessary Disclosure and, in either event, explain the circumstances. You should select “No” if you know that a Necessary Disclosure does not exist. You should select “None known and not reasonably ascertainable” if it is unduly burdensome to discover the correct response for reasons such as your workforce is so large that it is unreasonable to ascertain whether any Necessary Disclosures exist, and you in fact do not have knowledge of any Necessary Disclosure. Disclosure Statement 1: Employment by Vendor of a current Citizens employee or Board Member, or Relative of a current Citizens employee or Board Member. Check One: ☐ Yes ☐ No ☐ None known and not reasonably ascertainable. If you answered Yes, please explain: If you answered “None known and not reasonably ascertainable,” please state reason why the answer is not reasonably ascertainable: Disclosure Statement 2: Employment by Vendor of a former Citizens Senior Manager or Board Member, or Relative of a former Citizens Senior Manager or Board Member. Check One: ☐ Yes ☐ No ☐ None known and not reasonably ascertainable. If you answered Yes, please explain: If you answered “None known and not reasonably ascertainable,” please state reason why the answer is not reasonably ascertainable:
04%20-%20Attachment%20C%20-%20Vendor%20Conflict%20of%20Interest%20Disclosure%20Form.docx