FORM D
PRIOR NOTICE OF A TRANSACTION
Filed with the Insurance Division/Department of the State of ______
By
_________________
(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 the following information for each party to the transaction:
Furnish the following information for each transaction for which notice is being given:
Furnish a brief description of the amount and source of funds, securities, property, or other consideration involved in the sale, purchase, exchange, loan, extension of credit, guarantee, or investment related to the transaction, a statement of whether a provision exists for purchase by the insurer filing notice, by any party to the transaction, or by any affiliate of the insurer filing notice; a description of the terms of any securities being received; and a description of any other agreements relating to the transaction such as service contracts or consulting agreements. If the transaction involves consideration other than cash, furnish a description of the consideration, its cost, its fair market value, and an explanation of the basis for evaluation.
If the transaction involves a loan, extension of credit, or a guarantee, furnish a description of the maximum amount that the insurer will be obligated to make available under the loan, extension of credit, or guarantee; the date on which the credit or guarantee will terminate; and any provision for the accrual or deferral of interest.
If the transaction involves an investment, guarantee, or other arrangement, state the time period during which the investment, guarantee, or other arrangement will remain in effect, including any provision for an extension or renewal. Furnish a brief statement regarding the effect of the transaction upon the insurer's surplus.
Unless otherwise required by the director or required by statute, a notice is not required if, as of the last December 31st, the maximum amount that can be outstanding or for which the insurer can be legally obligated under the loan, extension of credit, or guarantee is less than
If the transaction involves a loan or extension of credit to a person that is not an affiliate, furnish a brief description of the agreement or understanding in which the proceeds of the proposed transaction, in whole or substantial part, are to be used to make a loan or extension of credit to, purchase the assets of, or make an investment in, an affiliate of the insurer making the loan or extension of credit. Specify in what manner the proceeds are to be used to loan to, extend credit to, purchase assets of, or make investments in an affiliate. Describe the amount and source of funds, securities, property, or other consideration for the loan or extension of credit and, if the transaction involves consideration other than cash, furnish a description of the consideration, its cost, its fair market value, and an explanation of the basis for evaluation. Furnish a brief statement regarding the effect of the transaction upon the insurer's surplus. Unless otherwise required by the director or required by statute, a notice is not required if, as of the last December 31st, the loan or extension of credit is less than
If the transaction is a reinsurance agreement or modification of it under AS 21.22.085(a)(3)(B) or a reinsurance pooling agreement or modification to it as described under AS 21.22.085(a)(3)(A), furnish a description of the known and estimated amounts of liability to be ceded or assumed in a calendar year, the period of time during which the agreement is in effect, and a statement regarding whether an agreement or understanding exists between the insurer and non-affiliate that provides that a portion of the assets serving as consideration for the agreement will be transferred to one or more of the insurer's affiliates. Furnish a brief description of the consideration involved in the transaction and a brief statement regarding the effect of the transaction upon the insurer's surplus.
Unless otherwise required by the director or required by statute, a notice is not required for a reinsurance agreement or modification to it if, as of the last December 31st, the reinsurance premium or a change in the insurer's liabilities or the projected reinsurance premium or change in the insurer's liabilities in any of the next three years, in connection with a reinsurance agreement or modification to it is less than five percent of the insurer's surplus as regards policyholders. Notice must be given for all reinsurance pooling agreements including modifications to it.
For a management agreement or service contract, furnish a brief description of the agreement, or contract including its duration, the managerial responsibilities or services to be performed, and the basis for and terms of payment of compensation.
For a cost-sharing arrangement, furnish
Furnish a brief description of the transaction and the circumstances under which it was or will be accomplished. Furnish information regarding valuation and pricing of the transaction and any other applicable information. If the transaction is an investment, provide the current purchase price, carrying value on the records of the holder of the investment, and current market value of the investment, along with information on how each value was determined.
Describe the action requested of the director. Provide a brief discussion concerning approval or disapproval of the requested action citing applicable law and alternate actions that may be taken if approval is not received.
As required under 3 AAC 21.140, provide a description of the extraordinary dividend or distribution for which approval is requested. Provide a brief discussion concerning approval or disapproval giving consideration to AS 21.22.080(5) and 21.22.090.
Use this section if approval under 3 AAC 21.281(g) for a life and health insurer or under 3 AAC 21.370(g) for a property and casualty insurer is being sought. Furnish the calculations required to determine that the thresholds under 3 AAC 21.281(g) or 3 AAC 21.370(g) are met.
Furnish discussion concerning the reason why, after the investment, the resultant policyholder surplus will be reasonable in relation to the organization's outstanding liabilities and adequate to the organization's financial need.
Furnish a schedule showing the effect on the surplus of the parties to the transaction and a discussion concerning the reason why, under AS 21.22.080, the resultant policyholder surplus will be reasonable in relation to the organization's outstanding liabilities and adequate to the organization's financial needs, giving consideration to AS 21.22.090.
Furnish a description of the material transaction in which the parties intend to engage, including the amount of fees to be charged and support for the reasonableness of those fees. Provide a statement affirming that the parties to the proposed transaction will comply with AS 21.22.080.
Furnish other information pertinent to the approval or pre-approval sought. If a Form A, an application for a certificate of authority, or another filing for the company or affiliate of the company is pending before the director, identify and describe the associated filing.
Signature and certification are required as follows:
SIGNATURE
Under the requirements of AS 21.22.080 - 21.22.105, ____________ has caused this notice 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 notice dated ______________, 20 ___, for and on behalf of ________________(Name of Applicant); 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 21.185
Authority:AS 21.06.090
AS 21.22.070
AS 21.22.080
AS 21.22.130