Ill. Admin. Code tit. 50, pt. 652, ILLUSTRATION C
FORM C
SUMMARY OF CHANGES TO REGISTRATION STATEMENT
Filed with the Department
of Insurance of the State of Illinois
By
___________________________________
Name of Registrant
On Behalf of the Following Insurance Companies
NameAddress
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Date: ___________, 20_________________________________________
Name, Title, Address and telephone number of Individual to Whom Notices and Correspondence Concerning This Summary Should Be Addressed:
__________________________________________________________
__________________________________________________________
__________________________________________________________
Furnish a brief description of all items in the current annual registration statement that represent changes from the prior year's annual registration statement. The description shall include specific references to item numbers in the annual registration statement and to the terms contained in the item. Changes occurring under Item 2, insofar as changes in the percentage of each class of voting securities held by each affiliate is concerned, need only be included if the changes are ones that result in ownership or holdings of 10% or more of voting securities, or loss or transfer of control or acquisition or loss of partnership interest. Changes occurring under Item 4 of the annual registration statement need only be included if: (1) an individual is, for the first time, made a director or executive officer of the ultimate controlling person or (2) a director or executive officer terminates his or her responsibilities with the ultimate controlling person.
If a transaction disclosed on the prior year's annual registration statement has been amended, the nature of the amendment shall be included. If a transaction disclosed on the prior year's annual registration statement has been completed, furnish the mode of completion and any flow of funds between affiliates resulting from the transaction.
The insurer shall furnish statements 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, disclosure and the review that might otherwise occur pursuant to Section 131.20 a of the Code.
SIGNATURE Signature and certification of the form as follows:
SIGNATURE
Pursuant to 50 Ill. Adm. Code 652.40, the Registrant has caused this summary of registration statement to be duly signed on its behalf in the City of _______________State of________ on the _______day of__________ , 20___.
_____________________________ (Name of Registrant) |
_____________________________ (Name)(Title) |
Attest:
_____________________ (Signature of Officer) |
_____________________ (Title) |
CERTIFICATION
The undersigned deposes and says that (s)he has duly executed the attached summary of registration statement dated _________________, 20____ , for and on behalf of ______ (Name of Company)_______; that (s)he is the ______(Title of Officer)______ of that company, and that (s)he is authorized to execute and file the instrument. Deponent further says that (s)he is familiar with the instrument and that the facts set forth in the instrument are true to the best of his/her knowledge, information and belief.
_____________________________ (Signature) |
_____________________________ (Type or Print Name) |
Ill. Admin. Code tit. 50, pt. 652, ILLUSTRATION C