Minn. R. 2715.6401
Current through Register Vol. 48, No. 51, June 17, 2024
| INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF EQUITY SECURITIES | |
| (File with Respect to Domestic Stock Insurer Pursuant to Minnesota Statutes, Section 60A.22) | |
| Name of Insurer: | |
| Address: | |
| Name of Person Whose Ownership is Reported: | |
| Address: | |
| Relationship of Such Person to Insurer (See Part 2715.6402, Subpart 4): | |
| Date Indicated Relationship Occurred: |
EQUITY SECURITIES BENEFICIALLY OWNED
| Title of Security (See Part 2715.6402, Subpart 5) | Nature of Ownership (See Part 2715.6402, Subpart 6) | Amount Beneficially Owned (See Part 2715.6402, Subpart 7) |
Remarks (See Part 2715.6402, Subpart 8):
| I affirm under penalty of perjury that the foregoing is full, true, and correct. | |
| Date of Statement: | |
| Where Made: | _____ |
| (Signature) |
Minn. R. 2715.6401
Statutory Authority: MS s 60A.22