Illinois Administrative Code
Title 50 - INSURANCE
Part 203 - PROXIES, CONSENTS AND AUTHORIZATIONS OF DOMESTIC STOCK COMPANIES
Exhibit B - Information to be Included in Statements Filed By or on Behalf of a Participant (Other than the Company in a Proxy Solicitation in an Election Contest)
Universal Citation: 50 IL Admin Code ยง B
Current through Register Vol. 48, No. 12, March 22, 2024
Item 1. Company. State the name and address of the company.
Item 2. Identity and Background.
a)
State the following:
1) Your name and
business address; and
2) Your
present principal occupation or employment and the name, principal business and
address of any corporation or other organization by which you are
employed.
b) State the
following:
1) Your residence address, age,
birthplace, birthdate, and social security number; and
2) Information as to all material
occupations, positions, offices or employments during the last 10 years, giving
starting and ending dates of each and the name, principal business and address
of any business corporation or other business organization for which each
occupation, position, office or employment was carried on.
c) State whether or not you are or have been
a participant in any other proxy contest involving this company or other
companies within the past 10 years. If so, identify the principals, the subject
matter and your relationship to the parties and the outcome.
d) State whether or not, during the past 10
years, you have been convicted in a criminal proceeding (excluding traffic
violations or similar misdemeanors) and, if so, give dates, nature of
conviction, name and location of court, and penalty imposed or other
disposition of the case. A negative answer to this sub-item need not be
included in the proxy statement or other proxy soliciting material.
Item 3. Interest in Securities of the Company.
a) State the
amount of each class of securities of the company which you own beneficially,
directly or indirectly.
b) State
the amount of each class of securities of the company which you own of record
but not beneficially.
c) State with
respect to all securities of the company purchased or sold within the past 2
years, the dates on which they were purchased or sold and the amount purchased
or sold on each date.
d) If any
part of the purchase price or market value of any of the securities specified
in paragraph (c) is represented by funds borrowed or otherwise obtained for the
purpose of acquiring or holding those securities, so state and indicate the
amount of the indebtedness as of the latest practical date. If the funds were
borrowed or obtained other than pursuant to a margin account or bank loan in
the regular course of business of a bank, broker or dealer, describe the
transaction, and state the names of the parties.
e) State whether or not you are a party to
any contract, arrangements or understandings with any persons concerning any
securities of the company, including but not limited to joint ventures, loan or
option arrangements, puts or calls, guarantees against losses or guarantees of
profits, division of losses or profits, or the giving or withholding of
proxies. If so, name any persons with whom such contracts, arrangements, or
understandings exist and give the details thereof.
f) State the amount of securities of the
company owned beneficially, directly or indirectly, by each of your associates
and the name and address of each of those associates.
g) State the amount of each class of
securities of any parent, subsidiary or affiliate of the company which you own
beneficially, directly or indirectly.
Item 4. Further Matters.
a) Describe the time and circumstances under
which you became a participant in the solicitation and state the nature and
extent of your activities or proposed activities as a participant.
b) Describe briefly, and where practical
state the approximate amount of any material interest, direct or indirect, of
yourself and of each of your associates in any material transactions since the
beginning of the company's last fiscal year, or in any material proposed
transactions, to which the company or any of its subsidiaries or affiliates was
or is to be a party.
c) State
whether or not you or any of your associates have any arrangement or
understanding with any person:
1) with
respect to any future employment by the company or its subsidiaries or
affiliates; or
2) with respect to
any future transactions to which the company or any of its subsidiaries or
affiliates will or may be a party.
If so, describe that arrangement or understanding and state the names of the parties thereto.
Item 5. Signature.
The statement must be dated and signed in the following manner:
I certify that the statements made in this statement are true, complete, and correct, to the best of my knowledge and belief.
_______________ _________________________________________
(Date)(Signature of Participant or Authorized Representative)
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