Applicant agrees to provide, to the best of its knowledge and belief, the information required by form F within fifteen (15) days after the end of the month in which the acquisition of control occurs.
ITEM 14. SIGNATURE AND CERTIFICATION
Signature and certification required as follows:
SIGNATURE
Pursuant to the requirements of ch. Ins 40, Wis. Adm. Code, has caused this application to be duly signed on its behalf in the city of and state of on the day of , .
(SEAL)
Name of Applicant
BY________________
(Name) (Title)
Attest:
________________
(Signature of Officer)
________________
(Title)
The undersigned deposes and says that (s)he has duly executed the attached application dated___________________________ , for and on behalf of____________; that (s)he is the_________ of such company and ____________________________________
(Name of Applicant)
that (s)he is authorized to execute and file such instrument.
Deponent further says that (s)he is familiar with the instrument and the contents thereof, and that the facts therein set forth are true to the best of his/her knowledge, information and belief.
__________________
(Signature)
__________________
(Type or print name beneath)
Subscribed and sworn to this
________________________________day of____ ,_________
Notary Public
My commission expires on _______________
FORM B
INSURANCE HOLDING COMPANY SYSTEM
ANNUAL REGISTRATION STATEMENT
Filed with the Office of the Commissioner of Insurance,
State of Wisconsin
By
____________________________
Name of Registrant
On behalf of following insurers
Name: Address:
Date:_______________, ________
Name, title, address and telephone number of individual to whom notices and correspondence concerning this statement should be addressed:
ITEM 1. IDENTITY AND CONTROL OF REGISTRANT
Furnish the exact name of each insurer registering or being registered (hereinafter called “the Registrant”), the home office address and principal executive offices of each; the date on which each registrant became part of the insurance holding company system; and the method(s) by which control of each registrant was acquired and is maintained.
ITEM 2. ORGANIZATIONAL CHART
Furnish a chart or listing clearly presenting the identities of and interrelationships among all affiliate persons within the insurance holding company system. The chart or listing should show the percentage of each class of voting securities of each affiliate which is owned, directly or indirectly, by another affiliate. If control of any person within the system is maintained other than by the ownership or control of voting securities, indicate the basis of control. As to each person specified in the chart or listing indicate the type of organization (e.g.,—corporation, trust, partnership) and the state of domicile.
ITEM 3. THE ULTIMATE CONTROLLING PERSON
As to the ultimate controlling person in the insurance holding company system furnish the following information:
(a) Name;
(b) Home office address;
(c) Principal executive office address;
(d) The organizational structure of the person, i.e., corporation, partnership, individual, trust, etc.;
(e) The principal business of the person;
(f) The name and address of any person who holds or owns 10% or more of any class of voting security, the class of such security, the number of shares held of record or known to be beneficially owned, and the percentage of class so held or owned;
(g) If court proceedings involving a reorganization or liquidation are pending, indicate the title and location of the court, the nature of proceedings and the date when commenced.
ITEM 4. BIOGRAPHICAL INFORMATION
If the ultimate controlling person is a corporation, an organization, a limited liability company, or other legal entity, furnish the following information for the directors and executive officers of the ultimate controlling person: the individual’s name and address, his or her principal occupation and all offices and positions held during the past 5 years, and any conviction of crimes other than traffic violations not involving death or injury. If the ultimate controlling person is an individual, furnish the individual’s name and address, his or her principal occupation and all offices and positions held during the past 5 years, and any conviction of crimes other than traffic violations not involving death of injury.
ITEM 5. TRANSACTIONS AND AGREEMENTS
Briefly describe the following agreements in force, and transactions currently outstanding or which have occurred during the last calendar year between the registrant and its affiliates:
(a) Loans, other investments, or purchases, sales or exchanges of securities of the affiliates by the Registrant or of the Registrant by its affiliates;
(b) Purchases, sales, extensions of credit or exchanges of assets;
(c) Transactions not in the ordinary course of business;
(d) Guarantees or undertakings for the benefit of an affiliate which result in an actual contingent exposure of the Registrant’s assets to liability, other than insurance contracts entered into in the ordinary course of the registrant’s business;
(e) All management agreements, exclusive agency agreements, service contracts and all cost-sharing arrangements;
(f) Reinsurance agreements;
(g) Dividends and other distributions to shareholders;
(h) Consolidated tax allocation agreements; and
(i) Any pledge of the Registrant’s stock or of the stock of any subsidiary or affiliate having control of the insurer, for a loan made to any member of the insurance holding company system.
No information need be disclosed if the information is not material according to s. Ins 40.03 (5), Wis. Adm. Code. Sales, purchases, exchanges, loans or extensions of credit, investments or guarantees involving .5% or less of the registrant’s admitted assets as of the 31st day of December next preceding shall not be deemed material.
Ins 40.21 NoteNote: Commissioner may by order provide otherwise.
The description shall be in a manner as to permit the proper evaluation thereof by the commissioner, and shall include at least the following: the nature and purpose of the transaction, the nature and amounts of any payments or transfers of assets between the parties, the identity of all parties to the transaction, and relationship of the affiliates of the registrant.
ITEM 6. LITIGATION OR ADMINISTRATIVE PROCEEDINGS
Briefly describe any litigation or administrative proceedings of the following types, either then pending or concluded within the preceding fiscal year, to which the ultimate controlling person or any of its directors or executive officers is or was a party or of which the property of any such person is or was the subject; give the names of the parties and the court or agency in which the litigation or proceeding was held or is pending:
(a) Criminal prosecutions or administrative proceedings by any government agency or authority which may be relevant to the trustworthiness of any party thereto; and
(b) Proceedings which may have a material effect upon the solvency or capital structure of the ultimate controlling person including, but not necessarily limited to, bankruptcy, receivership or other corporate reorganizations.
ITEM 7. STATEMENT REGARDING GROUP OR SERIES OF TRANSACTIONS
Furnish a statement that transactions entered into since the filing of the prior year’s annual registration statement are neither part of a group or series of related or like transactions nor made for the purpose of avoiding regulatory threshold amounts and the review that might otherwise occur. Groups or series of related transactions shall be treated as single transactions.
ITEM 8. FINANCIAL STATEMENTS AND EXHIBITS
(a) Attach financial statements and exhibits to this statement as an appendix, and list under this item the financial statements and exhibits so attached.
(b) If the ultimate controlling person is a corporation, an organization, a limited liability company, or other legal entity, the financial statements shall include the annual financial statements of the ultimate controlling person in the insurance holding company system as of the end of the person’s immediately preceding fiscal year.
If at the time of the initial registration, the annual financial statements for the immediately preceding fiscal year are not available, annual statements for the previous fiscal year may be filed and similar financial information shall be filed for any subsequent period to the extent such information is available. Such financial statements may be prepared either on an individual basis or unless the commissioner otherwise requires, on a consolidated basis if consolidated statements are prepared in the usual course of business.
Other than with respect to the foregoing, such financial statement shall be filed in a standard form and format adopted by the National Association of Insurance Commissioners unless an alternative form is accepted by the Commissioner. Documentation and financial statements filed with the Securities and Exchange Commission or audited GAAP financial statements shall be deemed to be an appropriate form and format.
Unless the commissioner otherwise permits, the annual financial statements shall be accompanied by the certificate of an independent public accountant to the effect that the statements present fairly the financial position of the ultimate controlling person and the results of its operations for the year then ended, in conformity with generally accepted accounting principles or with requirements of insurance or other accounting principles prescribed or permitted under law. If the ultimate controlling person is an insurer which is actively engaged in the business of insurance, the annual financial statements need not be certified, provided they are based on the annual statement of the insurer’s state of domicile and are in accordance with requirements of insurance or other accounting principles prescribed or permitted under the law and regulations of that state.
Any ultimate controlling person who is an individual may file personal financial statements that are reviewed rather than audited by an independent public accountant. The review shall be conducted in accordance with standards for review of personal financial statements published in the Personal Financial Statements Guide by the American Institute of Certified Public Accountants. Personal financial statements shall be accompanied by the independent public accountant’s Standard Review Report stating that the accountant is not aware of any material modifications that should be made to the financial statements in order for the statements to be in conformity with generally accepted accounting principles.
(c) Exhibits shall include copies of the last annual reports to shareholders of the ultimate controlling person, proxy material used by the ultimate controlling person, and any additional documents or papers required by form B or ch. Ins 40, Wis. Adm. Code. ITEM 9. FORM C REQUIRED
A form C, Summary of Changes to Registration Statement, must be prepared and filed with this form B.
ITEM 10. SIGNATURE AND CERTIFICATION
Signature and certification required as follows:
___________________________________________________
SIGNATURE
Pursuant to the requirements of ch. Ins 40, Wis. Adm. Code, Registrant has caused this annual registration statement to be duly signed on its behalf in the city of and state of ________on the _________ day of ______________ , ____________.
(SEAL)__________________
Name of Registrant
BY____________________
(Name) (Title) Attest:
_______________________________
(Signature of Officer)
_______________________________
(Title)
The undersigned deposes and says that (s)he has duly executed
the attached annual registration statement dated , for and on behalf of ;
(Name of Registrant)
that (s)he is the_________________ and that (s)he is authorized
(Title of Officer)
to execute and file such instrument. Deponent further says that (s)he is familiar with such instrument and the contents thereof, and that the facts therein set forth are true to the best of his/her knowledge, information and belief.
(Signature)
(Type or print name beneath)
Subscribed and sworn to this
_______day of______,_______.
Notary Public
My commission expires on________________
FORM C
SUMMARY OF CHANGES TO REGISTRATION
STATEMENT
Filed with the office of the commissioner of insurance,
state of Wisconsin
By
__________________________________
Name of Registrant
On behalf of following insurers
Name: Address:
Date: ,
Name, title, address and telephone number of individual to whom notices and correspondence concerning this statement should be addressed:
Furnish a brief description of all items in the annual registration statement, form B, which are required to be filed with this form, which represent changes from the prior year’s annual registration statement. The description shall be in a manner as to permit the proper evaluation thereof by the commissioner and shall include specific references to item numbers in the annual registration statement and to the terms contained therein.
Changes occurring under Item 2 of form B insofar as changes in the percentage of each class of voting securities held by each affiliate is concerned, need only be described where such changes are ones which result in ownership or holdings of 10% or more of voting securities, loss or transfer of control, or acquisition or loss of partnership interest.
Changes occurring under Item 4 of form B need only be described where an individual is, for the first time, made a director or executive officer of the ultimate controlling person; a director or executive officer terminates his or her responsibilities with the ultimate controlling person; or in the event an individual is named president of the ultimate controlling person.
If a transaction disclosed on the immediately prior year’s annual registration statement has been changed, the nature of such change shall be included. If a transaction disclosed on the prior year’s annual registration statement has been effectuated, describe the mode of completion and any flow of funds between affiliates resulting from the transaction.
The insurer shall furnish a statement that transactions entered into since the filing of the immediately prior year’s annual registration statement are not part of a group or series of like transactions or entered into for the purpose of avoiding reporting threshold amounts.
SIGNATURE
Signature and certification required as follows:
Pursuant to the requirements of ch. Ins 40, Wis. Adm. Code, Registrant has caused this annual summary of the registration statement to be duly signed on its behalf of the city of and State of on the day of , .
(SEAL)
Name of Registrant
BY
(Name) (Title)
Attest:
(Signature of Officer)
(Title) The undersigned deposes and says that (s)he has duly executed the attached annual registration statement dated, , for and on behalf of; that (s)he is the (Title of Officer)
of such Registrant and that (s)he is authorized to execute and file such instrument. Deponent further says that (s)he is familiar with such instrument and the contents thereof, and that the facts therein set forth are true to the best of his/her knowledge, information and belief.
(Signature)
(Type or print name beneath)
Subscribed and sworn to this
________day of___________, ______
Notary Public
My commission expires___________________
FORM D
PRIOR NOTICE OF A TRANSACTION
Filed with the office of the commissioner of insurance,
state of Wisconsin
By
_______________________________
Name of Registrant
On behalf of following insurers
Name: Address:
Date:__________ ,_________
Name, title, address and telephone number of individual to whom notices and correspondence concerning this statement should be addressed:
ITEM 1. IDENTITY OF PARTIES TO TRANSACTION
Furnish the following information for each of the parties to the transaction covered under s. 617.21 (2), Stats., and s. Ins 40.04 (2), Wis. Adm. Code: (a) Name;
(b) Home office address;
(c) Principal executive office address;
(d) The organizational structure, i.e., corporation, partnership, individual, trust, etc.;
(e) A description of the nature of the parties’ business operations;
(f) Relationship, if any, of other parties to the transaction to the insurer filing the notice, including any ownership or debtor/creditor interest by any other parties to the transaction in the insurer seeking approval, or by the insurer filing the notice for the affiliates;
(g) Where the transaction is with a non-affiliate, the name(s) of the affiliate(s) which will receive, in whole or in substantial part, the proceeds of the transaction.
ITEM 2. DESCRIPTION OF THE TRANSACTION
Furnish the following information for each transaction for which notice is being given:
(b) A statement of the nature of the transaction; and
(c) A statement of how the transaction meets the “fair and reasonable” standard of s. 617.21, Stats.; and (d) The proposed effective date of the transaction.
ITEM 3. SALES, PURCHASES, EXCHANGES, LOANS, EXTENSIONS OF CREDIT, GUARANTEES OR INVESTMENTS
