California Code of Regulations
Title 10 - Investment
Chapter 5 - Insurance Commissioner
Subchapter 4 - Insurer Securities Permits
Article 13 - Forms and Addenda
Section 2613.06 - Sample Form of Unconditional Subscription to Purchase Stock (with Cash Payment)

For convenient reference the following composite example of a form of subscription agreement for use under an organizational permit is provided. It is required that the substance of the last three paragraphs thereof be contained in any form of subscription agreement used where purchase money is collected and impounded.

SUBSCRIPTION TO PURCHASE STOCK OF A.B.C. INSURANCE COMPANY

I would like to purchase __________ shares of common capital stock of A.B.C. Insurance Company at $50.00 per share. The Stock Certificate should be registered as follows:

_________________________

_________________________

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Address

I hereby acknowledge receipt of a copy of Company's Prospectus dated __________, a copy of the Insurance Commissioner's Permit No. __________, and a copy of this subscription agreement.

Enclosed is my check (payable to A.B.C. Insurance Company) in the amount of $__________.

It is understood that the proceeds of my attached check or money order and all other stock purchase monies will be deposited in an impound with XYZ BANK, whose address is __________. In any event, the permit provides that stock purchase monies will not be impounded longer than one year without the consent of all subscribers.

Since there is a certain mutuality among subscribers, once a subscriber's deposit is made, it will not ordinarily be released from impound until the impound is terminated or the other subscribers consent to such release.

The impound will normally be terminated upon issuance of a certificate of authority to Company, whereupon all monies in impound will be paid over in full to Company and certificates for shares mailed to the purchasers. If the impound should be terminated for any other reason, stock purchase monies will be returned in full without interest to the subscribers, respectively, or in case of necessity to their successors in interest lawfully entitled thereto.

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Signature

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_________________________

Address

Received check for $__________ this __________ day of __________,199___.

A.B.C. INSURANCE COMPANY

_________________________

By _________________________

(Title or other description)