Illinois Administrative Code
Title 50 - INSURANCE
Part 655 - PRIOR NOTIFICATION OF DIVIDENDS ON COMMON STOCK AND OTHER DISTRIBUTIONS
ILLUSTRATION A - Form D-2
Current through Register Vol. 48, No. 12, March 22, 2024
FORM D-2
GENERAL INSTRUCTIONS
Signature and Certification.
For purposes of filing the Form D-2, the signature and certification required by this Part shall be signed by an executive officer of the insurer.
PRIOR NOTICE OF DIVIDENDS ON COMMON
STOCK AND OTHER DISTRIBUTIONS
Filed with the Illinois Department of Insurance
By
____________________________________ Name of Domestic Company |
On behalf of the Following Insurance Companies:
NameAddress
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Date __________, 20___
Name, Title, Address and Telephone Number of the Individual to Whom Notices and Correspondence Concerning this Request Should be Addressed:
______________________________________________________________
______________________________________________________________
______________________________________________________________
Item 1. Type of Dividend or Distribution.
Identify the dividend or distribution as a dividend or other distribution subject to Code Section 131.16 or as an extraordinary dividend or other extraordinary distribution as defined in Code Section 131.20 a(2).
Item 2. The amount of the dividend or other distribution and the date established for payment. The proposed date must be consistent with requirements for receipt of notice by the Department, as specified in Section 655.30(a).
Item 3. A statement as to whether the dividend or other distribution is to be in cash or other property, and, if in property, a description of the property, its cost, statutory carrying value, and the fair market value of the property, together with an explanation of the basis for valuation.
Item 4. The amounts and payment dates of all dividends paid within the period of 12 consecutive months ending on the date fixed for payment of the proposed dividend for which notification is being given or approval is being sought.
Item 5. An illustration of the calculation of the extraordinary dividend limit set by Code Section 131.20a. Dividends that have been or will be paid in other than cash shall be valued for the purposes of the calculation at the greater of market or statutory carrying value of the asset.
Item 6. If the notice is filed for an extraordinary dividend pursuant to Code Section 131.20a, the following items must also be included:
Pursuant to the requirements of Code Section 131.16 (or Sections 131.6 and 131.20a, in the case of extraordinary dividends), ______________ has caused this notice to be duly signed on its behalf in the City of _______________________ and State of ________ on the ________ day of ________, 20 __.
_____________________________ Name of Requesting Insurer |
|
By |
_____________________________ |
Type or print |
_____________________________ (Name)(Title) |
Attest:
____________________ (Signature of Officer) |
____________________ (Title) |
CERTIFICATION
The undersigned deposes and says that he or she had duly executed the attached notice dated ______________ , 20 ______, for and on behalf of _________(Name of Insurer)_________, that he or she is the __________(Title of Officer)___________ of the company and that he or she is familiar of the company and that he or she is familiar with the instrument and its contents, and that the facts set forth in that instrument are true to the best of his or her knowledge, information and belief.
(Signature) |
___________________ |
(Type or print name beneath) |
___________________ |