Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 40, subch. II, Appendix, form C
Filed with the office of the commissioner of insurance,
state of Wisconsin
By
Name of Registrant
On behalf of following insurers
Name: Address:
Date:_ _ ,_ _
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 annual registration statement, form B, which are required to be filed with this form, which represent changes from the prior year's annual registration statement. The description shall be in a manner as to permit the proper evaluation thereof by the commissioner and shall 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 described 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 described 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 immediately prior year's annual registration statement has been changed, the nature of such change shall be included. If a transaction disclosed on the prior year's annual registration statement has been effectuated, describe the mode of completion and any flow of funds between affiliates resulting from the transaction.
The insurer shall furnish a statement that transactions entered into since the filing of the immediately prior year's annual registration statement are not part of a group or series of like transactions or entered into for the purpose of avoiding reporting threshold amounts.
SIGNATURE
Signature and certification required as follows:
Pursuant to the requirements of ch. Ins 40, Wis. Adm. Code, Registrant has caused this annual summary of the registration statement to be duly signed on its behalf of the city of_ _ _ and State of_ _ _ on the_ _ day of_ _,.
(SEAL)_ _ _
Name of Registrant
BY_ _ _
(Name) (Title)
Attest:
_ _ _
(Signature of Officer)
_ _ _
(Title)
The undersigned deposes and says that (s)he has duly executed the attached annual registration statement dated,, for and on behalf of; that (s)he is the (Title of Officer) of such Registrant 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)
Subscribed and sworn to this
day of ,
Notary Public
My commission expires
Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 40, subch. II, Appendix, form C