191—4.26 (17A) Content of petition. A petition for waiver shall be typewritten or legibly handwritten in ink and include the following information where applicable and known to the petitioner:
	      1. 	  A caption which substantially conforms to the following example:
BEFORE THE INSURANCE COMMISSIONER OF THE STATE OF IOWA	
In the matter of: (name of person
requesting waiver or variance)	}	REQUEST FOR WAIVER OF RULE (specify number of rule for which
waiver is requested)	
	      2. 	  The name, address and telephone number of the entity or person for whom a waiver is being requested, and the case number of any related contested case.
	      3. 	  A description and citation of the specific rule from which a waiver is requested.
	      4. 	  The specific waiver requested, including the precise scope and duration.
	      5. 	  The relevant facts that the petitioner believes would justify a waiver under each of the criteria described in rule 4.24(17A). This statement shall include a signed statement from the petitioner attesting to the accuracy of the facts provided in the petition and a statement of reasons that the petitioner believes will justify a waiver.
	      6. 	  A history of any prior contacts between the insurance division and the petitioner relating to the regulated activity, application or license affected by the proposed waiver, including a description of each affected license held by the petitioner, any notices of violation, contested case hearings, or investigative reports relating to the regulated activity or license within the prior five years and any waivers or waiver applications filed by the petitioner with the insurance division within the prior five years.
	      7. 	  Any information known to the petitioner regarding the insurance division’s treatment of similar cases.
	      8. 	  The name, address and telephone number of any public agency or political subdivision which also regulates the activity in question, or which might be affected by the granting of a waiver.
	      9. 	  The name, address and telephone number of any entity or person who would be adversely affected by the granting of a waiver.
	      10. 	  The name, address and telephone number of any person with knowledge of the relevant facts relating to the proposed waiver.
	      11. 	  Signed releases of information authorizing persons with knowledge regarding the request to furnish the insurance division with information relevant to the waiver.