Current through Register Vol. 50, No. 9, September 20, 2024
A. Instructions
1. Persons Required to File Statements
a. Statements on this form are required to be
filed by every person who at any time during any calendar month was directly or
indirectly the beneficial owner of more than 10 percent of any class of equity
security of a domestic stock insurance company, or a director or officer of the
company which is the issuer of such securities, and who during such month had
any change in his beneficial ownership of any class of equity security of such
company.
2. When
Statements Are to Be Filed
a. Statements are
required to be filed on or before the tenth day after the end of each month in
which any change in beneficial ownership has occurred. Statements are not
deemed to have been filed with the commissioner until they have actually been
received by him.
3.
Where Statements Are to Be Filed
a. One signed
copy of each statement shall be filed with the Commissioner of Insurance, P. 0.
Box 44214, Baton Rouge, Louisiana.
4. Separate Statement for Each Company
a. A separate statement shall be filed with
respect to the securities of each company.
5. Relationship of Reporting Person to
Company
a. Indicate clearly the relationship
of the reporting person to the company, for example, "Director", "Director and
Vice President", "Beneficial owner of more than 10 percent of the company's
common stock", etc.
6.
Transactions and Holdings to Be Reported
a.
Every transaction shall be reported even though purchases and sales during the
month are equal or the change involves only the nature of ownership, for
example, from direct to indirect ownership. Beneficial ownership at the end of
the month of all classes of securities required to be reported shall be shown
even though there has been no change during the month in the ownership of
securities of one or more classes.
7. Title of Security
a. The statement of the title of the security
shall be such as clearly to identify the security even though there may be only
one class, for example, "Class A Common Stock", "Common Stock", etc.
8. Date of Transaction
a. The exact date (month, day and year) of
each transaction shall be stated opposite the amount involved in the
transaction.
9.
Statement of Amounts of Securities
a. In
stating the amount of the securities acquired, disposed of, or beneficially
owned, give the face amount of debt securities or the number of shares or other
units of other securities. In the case of securities owned indirectly (i.e.,
through a partnership, corporation, trust or other entity) the entire amount of
securities involved in the transaction or owned by the partnership,
corporation, trust or other entity shall be stated. The person whose ownership
is reported may, if he so desires, also indicate in a footnote or other
appropriate manner, the extent of his interest in the transaction or holdings
of the partnership, corporation, trust or other entity.
10. Nature of Ownership
a. Under "Nature of Ownership", state whether
ownership of the securities is "direct" or "indirect". If the ownership is
indirect (i.e., through a partnership, corporation, trust or other entity)
indicate in a footnote or other appropriate manner, the name or identity of the
medium through which the securities are indirectly owned. The fact that
securities are held in the name of a broker or other nominee does not, of
itself, constitute indirect ownership. Securities owned indirectly shall be
reported on separate lines from those owned directly and from those owned
through a different type of indirect ownership.
11. Character of Transaction
a. If the transaction was with the issuer of
the securities, so state. If it involved the purchase of securities through the
exercise of options, so state and give the exercise price per share. If any
other purchase or sale was effected otherwise than in the open market, that
fact shall be indicated. If the transaction was not a purchase or sale,
indicate its character (for example, gift, 5 percent stock dividend, etc.), as
the case may be. The foregoing information may be appropriately set forth in
the table or under "Remarks" at the end of the table.
12. Inclusion of Additional Information
a. A statement may include any additional
information or explanation deemed relevant by the person filing the
statement.
13. Signature
a. If the statement is filed for a
corporation, partnership, trust, etc., the name of the organization shall
appear over the signature of the officer or other person authorized to sign the
statement. If the statement is filed for an individual, it shall be signed by
him or specifically on his behalf by a person authorized to sign for
him.
REMARKS: (See instructions 11 and 12) I affirm under
penalty of perjury that the foregoing is full, true, and correct.
________________________________________________________________________________________________________________________
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
22:2.
