Wis. Admin. Code Office of the Commissioner of Insurance Ins 6.42
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State of Wisconsin
Commissioner of Insurance Form 3
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
(Filed pursuant to Wisconsin Administrative Code section Ins 6.42)
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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, state, zip code)
Relationship of such person to company named above. (See s. Ins 6.42(5))
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Date of event which requires the filing of this statement. (See s. Ins 6.42(6))
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Securities Beneficially Owned
Title of Security (See s. Ins 6.42(7)) | Nature of Ownership (See s. Ins 6.42(8) ) | Amount Owned Beneficially (See s. Ins 6.42(9) ) |
Remarks: (See s. Ins 6.42(10))
I affirm under penalty of perjury that the foregoing is full, true, and correct.
Date of statement
Signature
Wis. Admin. Code Office of the Commissioner of Insurance Ins 6.42