211 Mass. Reg. 7.14
FORM C
SUMMARY OF REGISTRATION STATEMENT
Filed with the Division of Insurance of the Commonwealth of Massachusetts
By
___________________________
Name of Registrant
On Behalf of Following Insurance Companies
Name Address
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Date:________________, 20______
Name, title, address, telephone number, and email of Individual to Whom Notices and Correspondence Concerning This Statement Should Be Addressed:
________________________________________________________________
________________________________________________________________
________________________________________________________________
Furnish a brief description of all items in the current annual registration statement 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 included 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 included 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 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, furnish 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 prior year's annual registration statement are not part of a plan or series of like transactions whose purpose it is to avoid statutory threshold amounts and the review that might otherwise occur.
SIGNATURE AND CERTIFICATION
Signature and certification required as follows:
____________________________________________
SIGNATURE
Pursuant to the requirements of M.G.L. c. 175, § 206C and 211 CMR 7.06(2), the 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____________, 20_____.
(SEAL)____________________
Name of Applicant
BY__________________
(Name) (Title)
Attest:
________________________
(Signature of Officer)
________________________
(Title)
CERTIFICATION
The undersigned deposes and says that he or she has duly executed the attached annual registration statement dated _______________________, 20 _______, for and on behalf of
_______________________________; that he or she is the____________________________
(Name of Company) (Title of Officer)
of such company and that (s)he is authorized to such execute and file instrument. Deponent further says that he or she 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)______________________________________________
211 CMR 7.14