Mont. Admin. r. 6.6.3717

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Current through Register Vol. 24, December 20, 2024

Rule 6.6.3717 - FORMS

(1) The following forms apply to this subchapter.

(a)FORM A

STATEMENT REGARDING THE

ACQUISITION OF CONTROL OF OR MERGER WITH A DOMESTIC INSURER

Name of Domestic Insurer

_________________________________

Name of Acquiring Person (Applicant)

Filed with the Office of the Montana State Auditor, Commissioner of Securities and Insurance

______________________________________________________________

(State of domicile of insurer being acquired)

Dated: _______________, 20____

Name, Title, Address, and Telephone Number of Individual to Whom Notices and Correspondence Concerning this Statement Should be Addressed:

______________________________________________________________

Items 1 through 13 remain the same.

(b)FORM B

INSURANCE HOLDING COMPANY SYSTEM ANNUAL REGISTRATION STATEMENT

Filed with the Office of the Montana State Auditor, Commissioner of Securities and Insurance

________________________________

Name of Registrant

On Behalf of Following Insurance Companies

Name Address

__________________________________________________________________

Date: ___________, 20___

Name, Title, Address, and Telephone Number of Individual to Whom Notices and Correspondence Concerning this Statement Should be Addressed:

__________________________________________________________________

Items 1 through 10 remain the same.

(c)FORM C

SUMMARY OF CHANGES TO REGISTRATION STATEMENT

Filed with the Office of the Montana State Auditor, Commissioner of Securities and Insurance

_______________________________

Name of Registrant

On Behalf of Following Insurance Companies

Name Address

__________________________________________________________________

Date: _____________, 20___

Name, Title, Address, and Telephone Number 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 must be in a manner as to permit the proper evaluation thereof by the commissioner, and must 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 must 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 must 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 the purpose of which is to avoid statutory threshold amounts and the review that might otherwise occur.

SIGNATURE AND CERTIFICATION

Signature and certification required as follows:

Pursuant to the requirements of 33-2-1111, MCA, the registrant has caused this summary of registration statement to be duly signed on its behalf in the city of _____________ and state of ________________ on the_______ day of _____________, 20___.

(SEAL) _________________________

Name of Registrant

By _________________________

(Name)

(Title)

Attest:

_______________________

(Signature of Officer)

_______________________

(Title)

CERTIFICATION

The undersigned certifies that (s)he has duly executed the attached summary of registration statement dated __________________, 20__, for and on behalf of ______________________ (Name of Applicant); that (s)he is the ______________ (Title of Officer) of such company and that (s)he is authorized to execute and file such instrument. Deponent further says that (s)he 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) ________________________

(d)FORM D

PRIOR NOTICE OF A TRANSACTION

Filed with the Office of the Montana State Auditor, Commissioner of Securities and Insurance

_________________________________

Name of Registrant

On Behalf of Following Insurance Companies

Name Address

______________________________________________________________

Date: _______________, 20___

Name, Title, Address, and Telephone Number of Individual to Whom Notices and Correspondence Concerning This Statement Should be Addressed:

__________________________________________________________________

Items 1 through 7 remain the same.

(e) FORM F

ENTERPRISE RISK REPORT

Filed with the Office of the Montana State Auditor, Commissioner of Securities and Insurance

..................................................................

Name of Registrant/Applicant

On Behalf of/Related to Following Insurance Companies

Name Address

..........................................................................................................................................................

Date: _________________________, 20______

Name, Title, Address, and Telephone Number of Individual to Whom Notices and Correspondence Concerning This Statement Should Be Addressed:

..........................................................................................................................................................

ITEM 1. ENTERPRISE RISK

The Registrant/Applicant, to the best of its knowledge and belief, shall provide information regarding the following areas that could produce enterprise risk as defined in 33-2-1101(3), MCA, provided such information is not disclosed in the Insurance Holding Company System Annual Registration Statement filed on behalf of itself or another insurer for which it is the ultimate controlling person:

Any material developments regarding strategy, internal audit findings, compliance or risk management affecting the insurance holding company system;

Acquisition or disposal of insurance entities and reallocating of existing financial or insurance entities within the insurance holding company system;

Any changes of shareholders of the insurance holding company system exceeding ten percent (10%) or more of voting securities;

Developments in various investigations, regulatory activities or litigation that may have a significant bearing or impact on the insurance holding company system;

Business plan of the insurance holding company system and summarized strategies for next 12 months;

Identification of material concerns of the insurance holding company system raised by supervisory college, if any, in last year;

Identification of insurance holding company system capital resources and material distribution patterns;

Identification of any negative movement, or discussions with rating agencies which may have caused, or may cause, potential negative movement in the credit ratings and individual insurer financial strength ratings assessment of the insurance holding company system (including both the rating score and outlook);

Information on corporate or parental guarantees throughout the holding company and the expected source of liquidity should such guarantees be called upon; and

Identification of any material activity or development of the insurance holding company system that, in the opinion of senior management, could adversely affect the insurance holding company system.

The Registrant/Applicant may attach the appropriate form most recently filed with the U.S. Securities and Exchange Commission, provided the Registrant/Applicant includes specific references to those areas listed in Item 1 for which the form provides responsive information. If the Registrant/Applicant is not domiciled in the U.S., it may attach its most recent public audited financial statement filed in its country of domicile, provided the Registrant/Applicant includes specific references to those areas listed in Item 1 for which the financial statement provides responsive information.

ITEM 2: OBLIGATION TO REPORT.

If the Registrant/Applicant has not disclosed any information pursuant to Item 1, the Registrant/Applicant shall include a statement affirming that to the best of its knowledge and belief, it has not identified enterprise risk subject to disclosure pursuant to Item 1.

Mont. Admin. r. 6.6.3717

NEW, 2014 MAR p. 501, Eff. 3/14/14; AMD, 2016 MAY p. 824, Eff. 5/7/2016

AUTH: 33-1-313, 33-2-1517, MCA; IMP: 33-2-1104, 33-2-1111, 33-2-1113, 33-2-1517, MCA