Form T-5A "Agency Financial Interest Report" - Missouri

What Is Form T-5A?

This is a legal form that was released by the Missouri Department of Insurance, Financial Institutions and Professional Registration - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 26, 2008;
  • The latest edition provided by the Missouri Department of Insurance, Financial Institutions and Professional Registration;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form T-5A by clicking the link below or browse more documents and templates provided by the Missouri Department of Insurance, Financial Institutions and Professional Registration.

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Download Form T-5A "Agency Financial Interest Report" - Missouri

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Agency Financial Interest Report
Date: ______________
Submitting title agency:
_________________________
Address:
_________________________
_________________________
1.
List your title agency’s financial interest in any other person or business.
2.
List all persons with a financial interest in the agency.
3.
List each material transaction between your title agency and those parties
listed in response to questions 1 and 2, above, including a description of
the transaction and a dollar amount of each transaction.
Agency’s Financial Interests in other Parties:
Material Transaction(s):
Party with Financial Interest in Agency:
Material Transaction(s):
* Update and re-submit this form within thirty (30) days of any material change to
the information submitted regarding the agency’s financial interests, parties with
financial interests in the agency, or parties with financial interests in the insurer,
agency or agent who are producers or associates of producers.
* Information related to material transactions collected pursuant to this Form T-5A
will be treated by the Department as a trade secret as defined by section
417.453(4), RSMo, inasmuch as such information possesses economic value by
virtue of its confidential status; the same or like information is unavailable through
other sources; and insurers have made reasonable efforts to maintain the
confidentiality of the data. As such, all information submitted pursuant to Form T-
5A, shall be considered confidential communications and immune from requests
made under chapter 610, RSMo, nor shall such information otherwise be made
available to the public or unauthorized individuals except in response a valid court
order.
DIFP
Form T-5A
Revised 06/26/2008
Agency Financial Interest Report
Date: ______________
Submitting title agency:
_________________________
Address:
_________________________
_________________________
1.
List your title agency’s financial interest in any other person or business.
2.
List all persons with a financial interest in the agency.
3.
List each material transaction between your title agency and those parties
listed in response to questions 1 and 2, above, including a description of
the transaction and a dollar amount of each transaction.
Agency’s Financial Interests in other Parties:
Material Transaction(s):
Party with Financial Interest in Agency:
Material Transaction(s):
* Update and re-submit this form within thirty (30) days of any material change to
the information submitted regarding the agency’s financial interests, parties with
financial interests in the agency, or parties with financial interests in the insurer,
agency or agent who are producers or associates of producers.
* Information related to material transactions collected pursuant to this Form T-5A
will be treated by the Department as a trade secret as defined by section
417.453(4), RSMo, inasmuch as such information possesses economic value by
virtue of its confidential status; the same or like information is unavailable through
other sources; and insurers have made reasonable efforts to maintain the
confidentiality of the data. As such, all information submitted pursuant to Form T-
5A, shall be considered confidential communications and immune from requests
made under chapter 610, RSMo, nor shall such information otherwise be made
available to the public or unauthorized individuals except in response a valid court
order.
DIFP
Form T-5A
Revised 06/26/2008