Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 7.00 - Massachusetts Insurance Holding Company System
Section 7.13 - Form B Instructions
Current through Register 1531, September 27, 2024
FORM B
INSURANCE HOLDING COMPANY SYSTEM ANNUAL REGISTRATION STATEMENT
Filed with the Division of Insurance of the Commonwealth of Massachusetts
By
________________________
Name of Registrant
On Behalf of Following Insurance Companies
Name Address
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Date:________________, 20_______
Name, title, address, telephone number, and email of Individual to Whom Notices and Correspondence Concerning This Statement Should Be Addressed:
___________________________________________________________
___________________________________________________________
___________________________________________________________
(1) ITEM 1. IDENTITY AND CONTROL OF REGISTRANT. Furnish the exact name of each insurer registering or being registered (hereinafter called "the Registrant"), the home office address and principal executive offices of each; the date on which each registrant became part of the insurance holding company system; and the method(s) by which control of each registrant was acquired and is maintained.
(2) ITEM 2. ORGANIZATIONAL CHART. Furnish a chart or listing clearly presenting the identities of and interrelationships among all affiliated persons within the insurance holding company system. No affiliate need be shown if its total assets are equal to less than U of 1% of the total assets of the ultimate controlling person within the insurance holding company system, unless it has assets valued at or exceeding $10 million.
The chart or listing should show the percentage of each class of voting securities of each affiliate which is owned, directly or indirectly, by another affiliate. If control of any person within the system is maintained other than by the ownership or control of voting securities, indicate the basis of control. As to each person specified in the chart or listing indicate the type of organization (e.g., corporation, trust, partnership) and the state or other jurisdiction of domicile.
(3) ITEM 3. THE ULTIMATE CONTROLLING PERSON. As to the ultimate controlling person in the insurance holding company system furnish the following information:
(4) ITEM 4. BIOGRAPHICAL INFORMATION. Furnish the following information for the directors and executive officers of the ultimate controlling person: the individual's name and address, his or her principal occupation and all offices and positions held during the past five years, and any conviction of crimes other than minor traffic violations during the past ten years.
(5) ITEM 5. TRANSACTIONS AND AGREEMENTS. Briefly describe the following agreements in force, and transactions currently outstanding or which have occurred during the last calendar year between the registrant and its affiliates:
No information need be disclosed if such information is not material for purposes of M.G.L. c. 175, § 206C(b). Sales, purchases, exchanges, loans or extensions of credit, investments or guarantees involving U of 1% or less of the registrant's admitted assets as of the 31st day of December next preceding shall not be deemed material.
The description shall be in a manner as to permit the proper evaluation thereof by the Commissioner, and shall include at least the following: the nature and purpose of the transaction, the nature and amounts of any payments or transfers of assets between the parties, the identity of all parties to the transaction, and relationship of the affiliated parties to the registrant.
(6) ITEM 6. LITIGATION OR ADMINISTRATIVE PROCEEDINGS. A brief description of any litigation or administrative proceedings of the following types, either then pending or concluded within the preceding fiscal year, to which the ultimate controlling person or any of its directors or executive officers was a party or of which the property of any such person is or was the subject; give the names of the parties and the court or agency in which the litigation or proceeding is or was pending:
(7) ITEM 7. STATEMENT REGARDING PLAN OR SERIES OF TRANSACTIONS. The insurer shall furnish a statement that transactions entered into since the filing of the prior year's annual registration statement are not part of a plan or series of like transactions, the purpose of which is to avoid statutory threshold amounts and the review that might otherwise occur.
(8) ITEM 8. FINANCIAL STATEMENTS AND EXHIBITS.
If at the time of the initial registration, the annual financial statements for the latest fiscal year are not available, annual statements for the previous fiscal year may be filed and similar financial information shall be filed for any subsequent period to the extent such information is available. Such financial statements may be prepared on either an individual basis; or, unless the Commissioner otherwise requires, on a consolidated basis if consolidated statements are prepared in the usual course of business.
Unless the Commissioner otherwise permits, the annual financial statements shall be accompanied by the certificate of an independent public accountant to the effect that the statements present fairly the financial position of the ultimate controlling person and the results of its operations for the year then ended, in conformity with generally accepted accounting principles or with requirements of insurance or other accounting principles prescribed or permitted under law. If the ultimate controlling person is an insurer which is actively engaged in the business of insurance, the annual financial statements need not be certified, provided they are based on the Annual Statement of the insurer filed with the insurance department of the insurer's domiciliary state and are in accordance with requirements of insurance or other accounting principles prescribed or permitted under the law and regulations of that state.
(9) ITEM 9. FORM C REQUIRED. A Form C, Summary of Registration Statement, must be prepared and filed with this Form B.
(10) ITEM 10. SIGNATURE AND CERTIFICATION. Signature and certification required as follows:
SIGNATURE
Pursuant to the requirements of M.G.L. c. 175, § 206C and 211 CMR 7.06(1), the Registrant has caused this annual registration statement to be duly signed on its behalf of the City of_________________and State of_____________on the__________day of__________, 20______.
(SEAL)______________________
Name of Registrant
BY___________________
(Name) (Title)
Attest:
__________________
(Signature of Officer)
__________________
(Title)
CERTIFICATION
The undersigned deposes and says that he or she has duly executed the attached annual registration statement dated______, 20___, for and on behalf of_________________________; that
(Name of Applicant he or she is the_____________________of such company and that he or she is authorized to
(Title of Officer)
execute and file such instrument. Deponent further says that he or she is familiar with such instrument and the contents thereof, and that the facts therein set forth are true to the best of his/her knowledge, information and belief.
(Signature)_________________________________________
(Type or print name beneath)______________________
