3 Alaska Admin. Code § 21.186
A domestic insurer including any person controlling a domestic insurer required to file notice under AS 21.22.010, and a nondomiciliary insurer licensed to do business in this state required to file notice under AS 21.22.065 of a proposed merger or acquisition shall furnish the required preacquisition notification information on Form E, made a part of this section in substantially the following form:
FORM E
PRE-ACQUISITION NOTIFICATION FORM REGARDING THE POTENTIAL COMPETITIVE IMPACT OF A PROPOSED MERGER OR ACQUISITION BY A NON-DOMICILIARY INSURER DOING BUSINESS IN THIS STATE OR BY A DOMESTIC INSURER
_________________________
(Name of Applicant)
_________________________
(Name of Other Person Involved in Merger or Acquisition)
Filed with the Division/Department of Insurance of the State of _______
Date: ______________, 20 _____
Name, Title, Address, Electronic Mail Address, and Telephone Number of lndividual Completing This Statement:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
State the name and address of each person identified above who is providing notice of the person's involvement in a pending acquisition or change in corporate control.
State the name and address of each person affiliated with those listed in Item 1. Describe their affiliations. "Affiliated" has the meaning given in AS 21.22.200.
State the nature and purpose of the proposed merger or acquisition.
State the nature of the business performed by each person identified in response to Items 1 and 2.
State specifically what market and market share in each relevant insurance market each person identified in Items 1 and 2 currently experiences in this state. Provide historical market and market share data for each person identified in Items 1 and 2 for the past five years and identify the source of the data. Provide a determination as to whether the proposed acquisition or merger, if consummated, would violate the competitive standards of the state under AS 21.22.065( d). If the proposed acquisition or merger would violate competitive standards, provide justification of why the acquisition or merger would not substantially lessen competition or create a monopoly in the state. "Insurance market" has the meaning given in AS 21.22.200. Furnish the data and calculations necessary for the director to make a determination under AS 21.22.065( d).
Furnish calculations, discussion, or other information that would constitute "other substantial evidence" under AS 21.22.065(f) or would provide information supportive of AS 21.22.065(g).
Furnish other information pertinent to the approval or pre-approval sought. If a Form A, an application for 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. Note: The division may additionally choose to make additional calculations under AS 21.22.065 using the division's own data or data provided by the National Association of lnsurance Commissioners.
If a company is claiming an exemption from the requirements of AS 21.22.065 under the provisions of AS 21.22.065(j)(3), (5), or (7), furnish the relevant data, calculations, discussion, or other information necessary for the director to determine the appropriateness of the exemption.
If a company is claiming an exemption under the provisions of AS 21.22.065(j)(5)(A), a letter of pre-notification of acquisition may be submitted in lieu of a completed Form E.
Signature and certification are required as follows:
SIGNATURE
Under the requirements of AS 21.22.065, ______ 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 Applicant)
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 21.186
Authority:AS 21.06.090
AS 21.22.065
AS 21.22.130
AS 21.22.200