Wis. Admin. Code Office of the Commissioner of Insurance Ins 6.43
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State of Wisconsin
Commissioner of Insurance
Form 4
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
(Filed pursuant to Wisconsin Administrative Code section Ins 6.43)
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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)
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Relationship of such person to company named above. (See s. Ins 6.43(5))
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Statement of Calendar Month of ____, 2____
Changes During Month and Month-End Ownership (See s. Ins 6.43(6))
Title of Security s. Ins 6.43(7) | Date of Transaction s. Ins 6.43(8) | Amount Bought or otherwise acquired s. Ins 6.43(9) | Amount Sold or otherwise disposed of s. Ins 6.43(9) | Nature of Ownership s. Ins 6.43(10) | Nature of Ownership s. Ins 6.43(10) |
Remarks: (See s. Ins 6.43(11))
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 6.43