Ill. Admin. Code tit. 50, pt. 204, exh. A
STATE OF ILLINOIS
Director of Insurance
Form 1-Initial Statement of Beneficial Ownership of Securities
Filed pursuant to Section 28.1 of the Illinois Insurance Code
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(Name of insurance company)
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(Name of person whose ownership is reported)
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(Business address of such person; street, city, zone, state)
Relationship of such person to company named above. (See instruction 5) _________
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Date of event which requires the filing of this statement. (See Instruction 6) _________
SECURITIES BENEFICIALLY OWNED
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Title of Security (See instruction 7) Nature of Ownership Amount Owned
(See instruction 8) (See Instruction 9)
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__________________________________________________________________
REMARKS: (See instruction 10)
Subscribed and sworn to before me this _____ day of ____________A.D., _____.
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NOTARY PUBLICSIGNATURE
ILLINOIS DEPARTMENTAL REGULATIONS
STATE OF ILLINOIS
Director of Insurance
Form 1 - Instructions for Initial Statement of Beneficial Ownership of Securities
A statement on this form is required to be filed by every person who is directly or indirectly the beneficial owner of more than 10 percent of any class of equity security of an Illinois stock insurance company, or who is a director or an officer of such a company.
One signed, sworn true copy of each statement shall be filed with the Director of Insurance, State of Illinois, Springfield, Illinois 62767.
A separate statement shall be filed with respect to the securities of each company.
Indicate clearly the relationship of the reporting person to the company; for example, "Director", "Director and Vice President", "Beneficial owner of more that 10 percent of the company's common stock", etc.
The information as to beneficial ownership of securities shall be given as of January 31, 1966, or, in the case of persons who subsequently assume any of the relationships specified in Instruction 1, as of the date that relationship was assumed.
The statement of the title of a security shall be such as clearly to identify the security even though there may be only one class; for example, "Class A Common Stock", "5% Debentures Due 1965", etc.
Under "Nature of ownership", state whether ownership of the securities is "direct" or "indirect". If the ownership is indirect, i.e., through a partnership, corporation, trust or other entity, indicate, in a footnote or other appropriate manner, the name or identity of the medium through which the securities are indirectly owned. The fact that securities are held in the name of a broker or other nominee does not, of itself, constitute indirect ownership. Securities owned indirectly shall be reported on separate lines from those owned directly and also from those owned through a different type of indirect ownership.
In stating the amount of securities beneficially owned, give the face amount of debt securities or the number of shares or other units of other securities. In the case of securities owned indirectly, the entire amount of securities owned by the partnership, corporation, trust or other entity shall be stated. The person whose ownership is reported may, if he so desires, also indicate in a footnote, or other appropriate manner, the extent of his interest in the partnership, corporation, trust or other entity.
A statement may include any additional information or explanation deemed relevant by the person filing the statement.
If the statement is filed for a corporation, partnership, trust, etc., the name of the organization shall appear over the signature of the officer or other person authorized to sign the statement. If the statement is filed for an individual, it shall be signed by him or specifically on his behalf by a person authorized to sign for him.
In those cases where the statement is signed by someone other than the person whose ownership is being reported, documentary evidence of the signing authority shall be filed with the statement.
In all cases, the signature must be duly notarized.
Ill. Admin. Code tit. 50, pt. 204, exh. A