3 Alaska Admin. Code § 21.180

Current through September 25, 2024

Section 3 AAC 21.180 - Summary of registration statement filing; Form C

An insurer required to file a statement under AS 21.22.060 shall also furnish the required information on Form C, made a part of this section in substantially the following form:

FORM C

SUMMARY OF CHANGES TO REGISTRATION STATEMENT

Filed with the Insurance Division/Department of the State of _________

_________________

(Name of Registrant)

On Behalf of the Following Insurance Companies

Name Address

__________________________________________________________________________________________

Date: ______________, 20 _____

Name, Title, Address, Electronic Mail Address, and Telephone Number of lndividual to Whom Notices and Correspondence Concerning This Statement Should be Addressed:

__________________________________________________________________________________________

Furnish a brief description of all items in the current registration statement that represent changes from the most recently filed registration statement. The description must be in a manner to permit the proper evaluation by the director, and must include specific references to item numbers in the annual registration statement and to the terms contained in it.

Changes occurring under Item 2 of Form B, to the extent that changes in the percentage of each class of voting securities held by each affiliate are concerned, need only be included where the changes are ones that result in ownership or holdings of 10 percent 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 included when an individual is made a director or executive officer of the ultimate controlling person for the first time; a director's or executive officer's responsibilities for the ultimate controlling person are terminated; or an individual is named president, chief executive officer, treasurer, or chief financial officer of the ultimate controlling person.

If a transaction disclosed on the prior year's annual registration statement has been changed, the nature of the change must be included. If a transaction disclosed on the prior year's annual registration statement has been completed, furnish the mode of completion and any flow of funds between affiliates resulting from the transaction.

The insurer shall furnish a statement affirming that transactions entered into since the filing of the prior registration statement are not part of a plan or series of like transactions the purpose of which is to avoid statutory threshold amounts and the review that might otherwise occur.

SIGNATURE AND CERTIFICATION

Signature and certification are required as follows:

SIGNATURE

Under AS 21.22.060, the registrant has caused this summary of changes to registration statement to be signed on its behalf in the City or Community of ____________ and State of ____________, on the day of ____________, 20____.

(SEAL)

____________________

(Name of Registrant)

By ___________

(Name) (Title)

Attest:

____________________

(Signature of Officer)

____________________

(Title)

CERTIFICATION

The undersigned deposes and says that the undersigned has duly executed the attached summary of registration statement dated ____________, 20 ____, for and on behalf of __________________(Name of Company); that the undersigned is the _____________(Title of Officer) of the company; and that the undersigned is authorized to execute and file the instrument. The undersigned further says that the undersigned is familiar with the instrument and the contents of it and that the facts stated in it are true to the best of the undersigned's knowledge, information, and belief.

(Signature)

_______________________

(Type or print name below)

______________________

3 AAC 21.180

Eff. 10/21/92, Register 124; am 11/26/2015, Register 216, January 2016

Authority:AS 21.06.090

AS 21.22.060

AS 21.22.130