Ill. Admin. Code tit. 50, pt. 204, exh. B
STATE OF ILLINOIS
Director of Insurance
Form 2 - Statement of Changes in 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) ________
Statement for Calendar Month of ____________________, 19_____
CHANGES DURING MONTH AND MONTH-END OWNERSHIP (See instruction 6)
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Title of Security | Date of Transaction | Amount Bought or Otherwise Acquired | Amount sold or Otherwise Disposed of | Nature of Ownership | Amount Owned Beneficially at End of Month | |||||||||||||
(See Instruction 7) | (See Instruction 8) | (See Instruction 9) | (See Instruction 10) | (See Instruction 10) | (See Instruction 9) | |||||||||||||
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REMARKS: (See instruction 11) | ||||||||||||||||||
Subscribed and sworn to before me this ____ day of ______________ A.D., 19___.
ILLINOIS DEPARTMENTAL REGULATIONS
STATE OF ILLINOIS
Director of Insurance
Form 2- Instructions for Statement of Changes in Beneficial Ownership of Securities
Statements on this form are required to be filed by every person who at any time during any calendar month was directly or indirectly the beneficial owner of more than 10 percent of any class of equity security of an Illinois stock insurance company, or a director or officer of the company which is the issuer of such securities, and who during such month had any change in his beneficial ownership of any class of equity security of such company.
Statements are required to be filed on or before the 10th day after the end of each month in which any change in beneficial ownership has occurred. Statements are not deemed to have been filed with the Director until they have actually been received by him.
Separate Statement For Each Company.
Relationship of Reporting Person to Company.
Indicate clearly the relationship of the reporting person to the company; for example, "Director", "Director and Vice President", "Beneficial owner of more than 10 percent of the company's common stock", etc.
Every transaction shall be reported even though purchases and sales during the month are equal or the change involves only the nature of ownership; for example, from direct to indirect ownership. Beneficial ownership at the end of the month of all classes of securities required to be reported shall be shown even though there has been no change during the month in the ownership of securities of one or more classes.
The statement of the title of the 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.
The exact date (month, day and year) of each transaction shall be stated opposite the amount involved in the transaction.
In stating the amount of the securities acquired, disposed of, or 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, i.e., through a partnership, corporation, trust or other entity, the entire amount of securities involved in the transaction or 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 transaction or holdings of the partnership, corporation, trust or other entity.
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 the 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 from those owned through a different type of indirect ownership.
If the transaction was with the issuer of the securities, so state. If it involved the purchase of securities through the exercise of options, so state and give the exercise price per share. If any other purchase or sale was effected otherwise than in the open market, that fact shall be indicated. If the transaction was not a purchase or sale, indicated its character; for example, gift, 5% stock dividend, etc. as the case may be. The foregoing information may be appropriately set forth in the table or under "Remarks" at the end of the table.
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 is 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. B