Missouri Code of State Regulations
Title 20 - DEPARTMENT OF COMMERCE AND INSURANCE
Division 200 - Insurance Solvency and Company Regulation
Chapter 11 - Control and Management of Insurance Companies
Section 20 CSR 200-11.101 - Insurance Holding Company System Regulation with Reporting Forms and Instructions

(A) Forms A, B, C, D, E, and F are intended to be guides in the preparation of the statements required by sections 382.040- 382.230, RSMo. They are not intended to be blank forms which are to be filled in. These statements filed shall contain the numbers and captions of all items, but the text of the items may be omitted provided the answers are prepared in such a manner as to indicate clearly the scope and coverage of the items. All instructions, whether appearing under the items of the form or elsewhere, are to be omitted. Unless expressly provided otherwise, if any item is inapplicable or the answer is in the negative, an appropriate statement to that effect shall be made.

(B) Three (3) complete copies of each Form A statement and one(1) copy of each other statement, including exhibits and all other papers and documents filed as a part of it, shall be filed with the director by personal delivery or mail addressed to: Director of Insurance of the State of Missouri, Attention: Chief Financial Examiner, PO Box 690, Jefferson City, MO 65102-0690. At least one (1) of the copies shall be signed in the manner prescribed on the form. Unsigned copies shall be conformed. If the signature of any person is affixed pursuant to a power of attorney or other authority, the power or other authority also shall be filed with the statement.

(C) If an applicant requests a hearing on a consolidated basis under section 382.060.4, in addition to filing the Form A with the director, the applicant shall file a copy of Form A with the National Association of Insurance Commissioners (NAIC) in electronic form.

(D) Statements should be prepared electronically. Statements and exhibits shall be easily readable and suitable for printing, review, and reproduction. Debits in credit categories and credits in debit categories shall be designed so as to be clearly distinguishable as such on photocopies. Statements shall be in the English language and monetary values shall be stated in United States currency. If any exhibit or other paper or document filed with the statement is in a foreign language, it shall be accompanied by a translation into the English language and any monetary value shown in a foreign currency normally shall be converted into United States currency.

(A) Information required by any item of Forms A, B, D, E, or F may be incorporated by reference in answer or partial answer to any other item. Information contained in any financial statement, annual report, proxy statement, statement filed with a governmental authority, or any other document may be incorporated by reference in answer or partial answer to any item of Forms A, B, D, E, or F provided the document is filed as an exhibit to the statement. Excerpts of documents may be filed as exhibits if the documents are extensive. Documents currently on file with the director which were filed within three (3) years need not be attached as exhibits. References to information contained in exhibits or in documents already on file shall clearly identify the material and shall specifically indicate that this material is to be incorporated by reference in answer to the item. Matter shall not be incorporated by reference in any case where the incorporation would render the statement incomplete, unclear, or confusing.

(B) Where an item requires a summary or outline of the provisions of any document, only a brief statement shall be made as to the pertinent provisions of the document. In addition to this statement, the summary or outline may incorporate by reference particular parts of any exhibit or document currently on file with the director which was filed within three (3) years and may be qualified in its entirety by that reference. In any case where two (2) or more documents required to be filed as exhibits are substantially identical in all material respects except as to the parties thereto, the dates of execution or other details, a copy of only one (1) of these documents need be filed with a schedule identifying the omitted documents and setting forth the material details in which these documents differ from the filed document.

(A) Identifying the information, document, or report in question;

(B) Stating why the filing at the time required is impractical; and

(C) Requesting an extension of time for filing the information, document, or report to a specified date. The request for extension shall be deemed granted unless the director, within sixty (60) days after receipt, enters an order denying the request.

(A) "The Act" means sections 382.010-382.300, RSMo.

(B) "Executive officer" means chief executive officer, chief operating officer, chief financial officer, treasurer, secretary, controller, and any other individual performing functions corresponding to those performed by the foregoing officers under whatever title.

(C) "Foreign insurer" shall include an alien insurer except where clearly noted otherwise.

(D) "Ultimate controlling person" means that person which is not controlled by any other person.

(E) Unless the context otherwise requires, other terms found in these rules and in section 382.010 of the Act are used herein as defined in section 382.010, RSMo. Other nomenclature or terminology is used in accordance with Chapters 354 and 374 through 385, RSMo, or industry usage if not defined therein.

(A) If the person being acquired is deemed to be a domestic insurer solely because of the provisions of section 382.040.4 of the Act, the name of the domestic insurer on the cover page should be indicated as follows: ABC Insurance Company, a subsidiary of XYZ Holding Company.

(B) Where a section 382.040.4 insurer is being acquired, references to the insurer contained in Form A shall refer to both the domestic subsidiary insurer and the person being acquired.

(A) Pursuant to section 382.120 of the Act, an amendment to Form B shall be filed within fifteen (15) days after the end of any month in which there is a material change to the information provided in the annual registration statement.

(B) Amendments shall be filed in the Form B format with only those items which are being amended reported. Each amendment shall include at the top of the cover page "Amendment No. [insert number] to Form B for [insert year]" and shall indicate the date of the change and not the date of the original filing.

(A) Any authorized insurer may file an annual registration statement on behalf of any affiliated insurer(s) which is required under sections 382.100-382.180 of the Act. An annual registration statement may include information not required by the Act regarding any insurer in the insurance holding company system even if the insurer is not authorized to do business in this state. In lieu of an annual registration statement on Form B, the authorized insurer may file a copy of the annual registration statement or similar report which it is required to file in its state of domicile, provided-

(B) The question of whether the filing insurer is the principal insurance company in the insurance holding company system is a question of fact, and an insurer filing an annual registration statement or report in lieu of Form B on behalf of an affiliated insurer shall set forth a brief statement of facts which will substantiate the filing insurer's claim that it, in fact, is the principal insurer in the insurance holding company system.

(C) With the prior approval of the director, an unauthorized insurer may follow any of the procedures which could be done by an authorized insurer under subsection (14)(A).

(D) Any insurer may take advantage of the provisions of section 382.140 or 382.150 of the Act without obtaining the prior approval of the director. The director, however, reserves the right to require individual filings if s/he deems the filings necessary in the interest of clarity, ease of administration, or the public good.

(A) A disclaimer of affiliation or a request for termination of registration claiming that a person does not, or will not upon the taking of some proposed action, control another person (referred to as the subject) shall contain the following information:

(B) A request for termination of registration shall be deemed to have been granted unless the director, within thirty (30) days after s/he receives the request, notifies the registrant otherwise.

(A) An insurer required to give notice of a proposed transaction pursuant to section 382.195 of the Act shall furnish the required information on Form D.

(B) Agreements for cost sharing services and management services shall, at a minimum and as applicable-

(C) Amendments required to be filed under section 382.195 shall be filed in the Form D format. Each amendment shall include at the top of the cover page "Amendment No. [insert number] to [insert name of agreement]" and shall indicate the effective date of the change.

(A) Requests for approval of extraordinary dividends or any other extraordinary distribution to shareholders shall include the following:

(B) Subject to section 382.210 of the Act, each registered insurer shall report to the director all dividends and other distributions to shareholders within fifteen (15) business days following the declaration, including the same information required by paragraph (17)(A)4.

(a) State the name and address of the applicant seeking to acquire control over the insurer.

(b) If the applicant is not an individual, state the nature of its business operations for the past five (5) years, or for such lesser period as the applicant person and any of its predecessors shall have been in existence. Briefly describe the business intended to be done by the applicant and the applicant's subsidiaries.

(c) Furnish a chart or list clearly presenting the identities of and the interrelationships among the applicant and all affiliates of the applicant. Indicate in the chart or listing the percentage of voting securities of each such person which is owned or controlled by the applicant or by any other such person. If control of any person is maintained other than by the ownership or control of voting securities, indicate the basis of such control. As to each person specified in such chart or listing, indicate the type of organization (for example, corporation, trust, partnership) and the state or other jurisdiction of domicile. If court proceedings involving a reorganization or liquidation are pending with respect to any such person, set forth the title of the court, nature of proceedings, and the date when commenced.

Item 3. Identity and Background of Individuals Associated With the Applicant.

(a) Name and business address;

(b) Present principal business activity, occupation, or employment, including position and office held and the name, principal business, and address of any corporation or other organization in which the employment is carried on;

(c) Material occupations, positions, offices, or employment during the last five (5) years, giving the starting and ending dates of each and the name, principal business, and address of any business operation or other corporation in which each such occupation, position, office, or employment was carried on; if any such occupation, position, office, or employment required licensing by or registration with any federal, state, or municipal governmental agency, indicate such fact, the current status of the licensing or registration, and an explanation of any surrender, revocation, suspension, or disciplinary proceedings in connection with the licensing or registration;

(d) Whether or not such person has ever been convicted in a criminal proceeding (excluding minor traffic violations) during the last ten (10) years and, if so, give the date, nature of conviction, name and location of court, and penalty imposed or other disposition of the case;

(e) A character report from an independent third party listed in the Independent Third Parties for Furnishing Background Investigation Reports in All States document, or its successor, maintained by the National Association of Insurance Commissioners.

(a) Describe the nature, source, and amount of funds or other considerations used or to be used in effecting the merger or other acquisition of control. If any part of the same is represented or is to be represented by funds or other consideration borrowed or otherwise obtained for the purpose of acquiring, holding, or trading securities, furnish a description of the transaction, the names of the parties to the transaction, the relationship, if any, between the borrower and the lender, the amounts borrowed or to be borrowed, and copies of all agreements, promissory notes, and security arrangements relating thereto.

(b) Explain the criteria used in determining the nature and amount of such consideration.

(c) If the source of the consideration is a loan made in the lender's ordinary course of business and if the applicant wishes the identity of the lender to remain confidential, s/he must specifically request that the identity be kept confidential.

Item 5. Future Plans of Insurer.

Describe any plans or proposals which the applicant may have to declare an extraordinary dividend, to liquidate such insurer, to sell its assets to or merge it with any person or persons, or to make any other material change in its business operations or corporate structure or management.

Item 6. Voting Securities to be Acquired.

State the number of shares of the insurer's voting securities which the applicant, its affiliates, and any person listed in Item 3, plan to acquire, and the terms of the offer, request, invitation, agreement, or acquisition, and a statement as to the method by which the fairness of the proposal was arrived at.

Item 7. Ownership of Voting Securities.

State the amount of each class of any voting security of the insurer which is beneficially owned or concerning which there is a right to acquire beneficial ownership by the applicant, its affiliates, or any person listed in Item 3.

Item 8. Contracts, Arrangements, or Understandings With Respect to Voting Securities of the Insurer.

Give the full description of any contracts, arrangements, or understandings with respect to any voting security of the insurer in which the applicant, its affiliates, or any person listed in Item 3 is involved, including, but not limited to, transfer of any of the securities, joint ventures, loan or option arrangements, puts or calls, guarantees of loans, guarantees against loss or guarantees of profits, division of losses or profits, or the giving or withholding of proxies. This description shall identify the persons with whom the contracts, arrangements or understandings have been entered into.

Item 9. Recent Purchases of Voting Securities.

Describe any purchases of any voting securities of the insurer by the applicant, its affiliates, or any person listed in Item 3 during the twelve (12) calendar months preceding the filing of this statement. Include in such description the dates of purchase, the names of the purchasers, and the consideration paid or agreed to be paid. State whether any shares so purchased are hypothecated.

Item 10. Recent Recommendations to Purchase.

Describe any recommendations to purchase any voting security of the insurer made by the applicant, its affiliates or any person listed in Item 3, or by anyone based upon interviews or at the suggestion of the applicant, its affiliates or any person listed in Item 3 during the twelve (12) calendar months preceding the filing of this statement.

Item 11. Agreements With Broker-Dealers.

Describe the terms of any agreement, contract, or understanding made with any broker-dealer as to solicitation of voting securities of the insurer for tender and the amount of any fees, commission, or other compensation to be paid to broker-dealers with regard thereto.

(a) Attach financial statements, exhibits, and three-(3-) year financial projections of the insurer(s) to this statement as an appendix, but list under this item the financial statements and exhibits so attached.

(b) The financial statements shall include the annual financial statements of the persons identified in Item 2(c) for the preceding five (5) fiscal years (or for such lesser period as the applicant, its affiliates, and any predecessors of the applicant shall have been in existence), and similar information covering the period from the end of the person's last fiscal year, if this information is available. These statements may be prepared on either an individual basis or, unless the director otherwise requires, on a consolidated basis if consolidated statements are prepared in the usual course of business.

(c) The annual financial statements of the applicant shall be accompanied by the certificate of an independent public accountant to the effect that the statements present fairly the financial position of the applicant 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 applicant is an insurer which is actively engaged in the business of insurance, the financial statements need not be certified, provided they are based on the Annual Statement of such person filed with the insurance department of the person's domiciliary state and are in accordance with the requirements of insurance or other accounting principles prescribed or permitted under the law and regulations of such state.

(d) File as exhibits copies of all tender offers for, requests or invitations for, tenders of, exchange offers for, and agreements to acquire or exchange any voting securities of the insurer and (if distributed) of additional soliciting material relating thereto, any proposed employment, consultation, advisory, or management contracts concerning the insurer, annual reports to the stockholders of the insurer and the applicant for the last two (2) fiscal years, and any additional documents or papers required by Form A or 20 CSR 200-11.101(2) and (4).

Item 13. Agreement Requirements for Enterprise Risk Management.

Applicant agrees to provide, to the best of its knowledge and belief, the information required by Form F within fifteen (15) days after the end of the month in which the acquisition of control occurs. Applicant further agrees to annually provide Form F as described in section 382.175 of the Act for so long as control exists. Applicant further acknowledges that the applicant and all subsidiaries within its control in the insurance holding company system shall provide information to the director upon request as necessary to evaluate enterprise risk to the insurer.

Item 14. Signature and Certification.

Signature and certification required as follows:

SIGNATURE

Pursuant to the requirements of sections 382.040-382.060 of the Act ___________________________________ has caused this application to be duly signed on its behalf in the City of ____________________________ and State of ________________, on the __________ day of _________, _________.

(SEAL)

_______________________________________

(Name of Applicant)

by

_______________________________________

(Name)

_______________________________________

(Title)

Attest:

_______________________________________

(Signature of Officer)

_______________________________________

(Title)

CERTIFICATION

The undersigned deposes and says that s/he has duly executed the attached application dated ________________, ___________, for and on behalf of __________________________________________;

(Name of Applicant)

that s/he is the ____________________________________________

(Title of Officer)

of ______________________________________________________

(Name of Company)

and that s/he is authorized to execute and file such instrument. Deponent further says that s/he 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)

FORM B

Insurance Holding Company System Annual Registration Statement

Filed with the Insurance Department of the state of

_______________________________________

by

_______________________________________

(Name of Registrant)

On behalf of following insurance companies:

Name Address

_______________________________________

_______________________________________

_______________________________________

_______________________________________

Date ___________________, ____________.

Name, title, mailing address, e-mail address, and telephone number of individual to whom notices and correspondence concerning this statement should be addressed:

_______________________________________

_______________________________________

_______________________________________

Item 1. Identity and Control of Registrant.

Furnish the exact name of each insurer registering or being registered (after this 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.

Item 2. Organizational Chart.

Furnish a chart or listing clearly presenting the identities of and interrelationships among all affiliated persons with the insurance holding company system. 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 the control. As to each person specified in the chart or listing indicate the type of organization (for example, corporation, trust, partnership) and the state or other jurisdiction of domicile.

Item 3. The Ultimate Controlling Person.

(a) Name;

(b) Home office address;

(c) Principal executive office address;

(d) The organizational structure of the person, that is, corporation, partnership, individual, trust, etc;

(e) The principal business of the person;

(f) The name and address of any person who holds or owns ten percent (10%) or more of any class of voting security, the class of such security, the number of shares held of record or known to be beneficially owned, and the percentage of class so held or owned; and

(g) If court proceedings involving a reorganization or liquidation are pending, indicate the title and location of the court, the nature of proceedings, and the date when commenced.

Item 4. Biographical Information.

If the ultimate controlling person is a corporation, an organization, a limited liability company, or other legal entity, furnish the following information for the directors and executive officers of the ultimate controlling person: each individual's name and address, his/her principal occupation and all offices and positions held during the past five (5) years, and any conviction of crimes other than minor traffic violations. If the ultimate controlling person is an individual, furnish the individual's name and address, his or her principal occupation and all offices and positions held during the past five (5) years, and any conviction of crimes other than minor traffic citations.

Item 5. Transactions and Agreements.

(a) Loans, other investments, or purchases, sales, or exchanges of securities of the affiliates by the registrant or of the registrant by its affiliates;

(b) Purchases, sales, or exchanges of assets;

(c) Transactions not in the ordinary course of business;

(d) Guarantees or undertakings for the benefit of an affiliate which result in an actual contingent exposure of the registrant's assets to liability, other than insurance contracts entered into in the ordinary course of the registrant's business;

(e) All management agreements, service contracts, and cost-sharing arrangements;

(f) Reinsurance agreements;

(g) Dividends and other distributions to shareholders;

(h) Consolidated tax allocation agreements; and

(i) Any pledge of the registrant's stock, the stock of any subsidiary or controlling affiliate, or both, for a loan made to any member of the insurance holding company system.

No information need be disclosed if such information is not material for purposes of sections 382.100-382.180 of the Act.

Sales, purchases, exchanges, loans or extension of credit, investments or guarantees involving one-half (1/2) of one percent (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 by the director, 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 such transaction, and relationships of the affiliated parties to the registrant.

Item 6. Litigation or Administrative Proceedings.

(a) Criminal prosecutions or administrative proceedings by any government agency or authority which may be relevant to the trustworthiness of any party to the prosecutions or proceedings; and

(b) Proceedings which may have a material effect upon the solvency or capital structure of the insurance holding company system including, but not necessarily limited to, bankruptcy, receivership, or other corporate reorganizations.

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.

(a) Financial statements and exhibits should be attached to this statement as an appendix, but list under this item the financial statements and exhibits so attached.

(b) If the ultimate controlling person is a corporation, an organization, a limited liability company, or other legal entity, the financial statements shall include the annual financial statements of the ultimate controlling person in the holding company system as of the end of the person's latest fiscal year.

(c) 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. These financial statements may be prepared on either an individual basis, or unless the director otherwise requires, on a consolidated basis, if such consolidated statements are prepared in the usual course of business.

(d) Other than with respect to the foregoing, such financial statement shall be filed in a standard form and format adopted by the National Association of Insurance Commissioners, unless an alternative form is accepted by the director. Documentation and financial statements filed with the Securities and Exchange Commission or audited GAAP financial statements shall be deemed to be an appropriate form and format.

(e) Unless the director 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 such 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 such state.

(f) Any ultimate controlling person who is an individual may file personal financial statements that are reviewed rather than audited by an independent public accountant. The review shall be conducted in accordance with standards for review of personal financial statements published in the Personal Financial Statements Guide by the American Institute of Certified Public Accountants. Personal financial statements shall be accompanied by the independent public accountant's Standard Review Report stating that the accountant is not aware of any material modifications that should be made to the financial statements in order for the statements to be in conformity with generally accepted accounting principles.

(g) Exhibits shall include copies of the latest annual reports to shareholders of the ultimate controlling person and proxy materials used by the ultimate controlling person; and any additional documents or papers required by Form B or 20 CSR 200-11.101(2) and (4).

Item 9. Statement Regarding Corporate Governance and Internal Controls

Furnish statements that the insurer's board of directors oversees corporate governance and internal controls and that the insurer's officers or senior management have approved, implemented, and continue to maintain and monitor corporate governance and internal control procedures.

Item 10. Form C Required.

A Form C, Summary of Changes to Registration Statement, must be prepared and filed with this Form B.

Item 11. Signature and Certification.

Signature and certification required as follows:

SIGNATURE

Pursuant to the requirements of sections 382.100- 382.180 of the Act, the Registrant has caused this annual registration statement to be duly signed on its behalf in the City of _____________________________________________________ and the State of ______________________________ on the ___________ day of ___________________, _________.

(SEAL)

_______________________________________________________

(Name of Registrant)

by

_______________________________________________________

(Name)

_______________________________________________________

(Title)

Attest:

_______________________________________________________

(Signature of Officer)

_______________________________________________________

(Title)

CERTIFICATION

_______________________________________________________

The undersigned deposes and says that s/he has duly executed the attached annual registration statement dated ___________________,

______________________________, for and on behalf of

_______________________________________________________ ;

(Name of Officer)

that s/he is the ____________________________________________

(Title of Officer)

of ______________________________________________________

(Name of Company)

and that s/he is authorized to execute and file such instrument. Deponent further says that s/he 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)

FORM C

Summary of Changes to Registration

STATEMENT

Filed with the Insurance Department of the State of

_______________________________________________________

by

_______________________________________________________

(Name of Registrant)

On behalf of following insurance companies:

Name Address

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

Date ____________________, __________

Name, title, mailing address, e-mail address, and telephone number of individual to whom notices and correspondence concerning this statement should be addressed:

_______________________________________________________

_______________________________________________________

_______________________________________________________

Furnish a brief description of all items in the current annual registration statement which represent changes from the prior year's annual registration statement. The description shall be in a manner as to permit proper evaluation by the director, and shall include specific references to Item numbers in the annual registration statement and to the terms contained in the statement.

Changes occurring under Item 2 of Form B insofar as changes in the percentage of each class of voting securities held by each affiliate is concerned, need only be included where such changes are ones which result in ownership or holdings of ten percent (10%) or more of voting securities, loss or transfer of control, or acquisition or loss of partnership interest.

Changes occurring under Item 4 of Form B need only be included where an individual is, for the first time, made a director or executive officer of the ultimate controlling person; a director or executive officer terminates his/her responsibilities with the ultimate controlling person; or in the event an individual is named president of the ultimate controlling person.

If a transaction disclosed on the prior year's annual registration statement has been changed, the nature of this change shall be included. If a transaction disclosed on the prior year's annual registration statement has been effectuated, furnish the mode of completion and any flow of funds between affiliates resulting from the transaction.

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 whose purpose it is to avoid statutory threshold amounts and the review that might otherwise occur.

SIGNATURE AND CERTIFICATION

Signature and certification required as follows:

SIGNATURE

Pursuant to the requirements of sections 382.100-382.180 of the Act, the Registrant has caused this summary of registration statement to be duly signed on its behalf in the City of _____________________________________________________ and the State of ______________________________________________ on the ___________ day of _____________, ____________.

(SEAL)

__________________________________________

(Name of Registrant)

by

____________________________________

(Name)

____________________________________

(Title)

Attest:

____________________________________

(Signature of Officer)

____________________________________

(Title)

CERTIFICATION

The undersigned deposes and says that s/he has duly executed the attached summary of registration statement dated _________________________ , __________, for and on behalf of ___________________________________________ that s/he is the

(Name of Officer)

_____________________________________________________ of

(Title of Officer)

_______________________________________________________

(Name of Company)

that s/he is authorized to execute and file such instrument. Deponent further says that s/he 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)

FORM D

Prior Notice of a Transaction

Filed with the Insurance Department of the State of

____________________________________

____________________________________

by

____________________________________

(Name of Registrant)

On behalf of the following insurance companies:

Name Address

____________________________________

____________________________________

____________________________________

____________________________________

Date: ________________, ______________

Name, title, mailing address, e-mail address, and telephone number of individual to whom notices and correspondence concerning this statement should be addressed:

____________________________________

____________________________________

____________________________________

____________________________________

Item 1. Identity of Parties to Transaction.

(a) Name;

(b) Home office address;

(c) Principal executive office address;

(d) The organizational structure, that is, corporation, partnership, individual, trust, etc;

(e) A description of the nature of the parties' business operations;

(f) Relationship, if any, of other parties to the transaction to the insurer filing the notice, including any ownership or debtor/creditor interest by any other parties to the transaction in the insurer seeking approval, or by the insurer filing the notice in the affiliated parties; and

(g) Where the transaction is with a nonaffiliate, the name(s) of the affiliate(s) which will receive, in whole or in substantial part, the proceeds of the transaction.

Item 2. Description of the Transaction.

(a) A statement as to whether notice is being given under section 382.195.1(1), (2), (3), (4), (5), (6), or (7) of the Act;

(b) A statement of the nature of the transaction;

(c) A statement of how the transaction meets the fair and reasonable standard of section 382.190(1) of the Act; and

(d) The proposed effective date of the transaction.

Item 3. Sales, Purchases, Exchanges, Loans, Extensions of Credit, Guarantees, or Investments.

Furnish a brief description of the amount and source of funds, securities, property or other consideration for the sale, purchase, exchange, loan, extension of credit, guarantee, or investment, whether any provision exists for purchase by the insurer filing notice, by any party to the transaction, or by any affiliate of the insurer filing notice, a description of the terms of any securities being received, if any, and a description of any other agreements relating to the transaction such as contracts or agreements for services, consulting agreements and the like. If the transaction involves consideration other than cash, furnish a description of the consideration, its cost, and its fair market value, together with an explanation of the basis for valuation.

If the transaction involves a loan, extension of credit, or a guarantee, furnish a description of the maximum amount which the insurer will be obligated to make available under such loan, extension of credit, or guarantee, the date on which the credit or guarantee will terminate, and any provisions for the accrual of or deferral of interest.

If the transaction involves investments, guarantees, or other arrangements, state the time period during which the investments, guarantees, or other arrangements will remain in effect, together with any provisions for extensions or renewals of these investments, guarantees, or other arrangements. Furnish a brief statement as to the effect of the transaction upon the insurer's surplus.

(a) In the case of nonlife insurers, the lesser of three percent (3%) of the insurer's admitted assets or twenty-five percent (25%) of surplus as regards policyholders; or

(b) In the case of life insurers, three percent (3%) of the insurer's admitted assets, each as of the 31st day of December next preceding.

Item 4. Loans or Extensions of Credit to a Nonaffiliate.

If the transaction involves a loan or extension of credit to any person who is not an affiliate, furnish a brief description of the agreement or understanding where the proceeds of the proposed transaction, in whole or in substantial part, are to be used to make loans or extensions of credit to, to purchase the assets of, or to make investments in, any affiliate of the insurer making these loans or extensions of credit, and specify in what manner the proceeds are to be used to loan to, extend credit to, purchase assets of, or make investments in any affiliate. Describe the amount and source of funds, securities, property, or other consideration for the loan or extension of credit and, if the transaction is one involving consideration other than cash, a description of its cost and its fair market value, together with an explanation of the basis for valuation. Furnish a brief statement as to the effect of the transaction upon the insurer's surplus.

No notice need be given if the loan or extension of credit is one which equals less than, in the case of non-life insurers, the lesser of three percent (3%) of the insurer's admitted assets or twenty-five percent (25%) of surplus as regards policyholders or, with respect to life insurers, three percent (3%) of the insurer's admitted assets, each as of the 31st day of December next preceding.

Item 5. Reinsurance.

If the transaction is a reinsurance agreement or modification thereto, as described by section 382.195.1(3)(b) of the Act, or a reinsurance pooling agreement or modification thereto as described by section 382.195.1(3)(a) of the Act, furnish a description of the known and/or estimated amount of liability to be ceded and/or assumed in each calendar year, the period of time during which the agreement will be in effect, and a statement whether an agreement or understanding exists between the insurer and nonaffiliate to the effect that any portion of the assets constituting the consideration for the agreement will be transferred to one (1) or more of the insurer's affiliates. Furnish a brief description of the consideration involved in the transaction and brief statement as to the effect of the transaction upon the insurer's surplus.

No notice need be given for reinsurance agreements or modifications thereto if the reinsurance premium or a change in the insurer's liabilities, or the projected reinsurance premium or change in the insurer's liabilities in any of the next three years, in connection with the reinsurance agreement or modification thereto is less than five percent (5%) of the insurer's surplus as regards policyholders, as of the 31st day of December next preceding. Notice shall be given for all reinsurance pooling agreements including modifications thereto.

Item 6. Management Agreements, Service Agreements, Tax Allocation Agreements, and Cost-Sharing Arrangements.

(a) A brief description of the managerial responsibilities or services to be performed; and

(b) A brief description of the agreement, including a statement of its duration, together with brief descriptions of the basis for compensation and the terms under which payment or compensation is to be made;

(a) A brief description of the purpose of the agreement or arrangement;

(b) A description of the period of time during which the agreement or arrangement is to be in effect;

(c) A brief description of each party's expenses or costs covered by the agreement or arrangement; and

(d) A brief description of the accounting basis to be used in calculating each party's costs under the agreement or arrangement;

(e) A brief statement as to the effect of the transaction upon the insurer's policyholder surplus;

(f) A statement regarding the cost allocation methods that specifies whether proposed charges are based on cost or market. If market based, furnish rationale for using market instead of cost, including justification for the company's determination that amounts are fair and reasonable; and

(g) A statement regarding compliance with the NAIC Accounting Practices and Procedures Manual regarding expense allocation.

Item 7. Signature and Certification. Signature and certification required as follows:

SIGNATURE

Pursuant to the requirements of section 382.195 of the Act _________________________________________________ has caused this application to be duly signed on its behalf in the City of ___________________________________ and State of _____________________________ on the __________ day of ______________, ______________.

(SEAL)

_______________________________________

(Name of Applicant)

by

________________________ ________________________

(Name) (Title)

Attest:

_______________________________________

(Signature of Officer)

_______________________________________

(Title)

CERTIFICATION

The undersigned deposes and says that s/he has duly executed the attached notice dated ___________________, _________________, for and on behalf of _______________________________________

(Name of Officer)

that s/he is the __________________________________________ of

(Title of Officer)

_______________________________________________________

(Name of Company)

and that s/he is authorized to execute and file such instrument. Deponent further says that s/he 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)

FORM E

Pre-Acquisition Notification Form Regarding the Potential Competitive Impact of a Proposed Merger or Acquisition by a Non-Domiciliary Insurer Doing Business in this State or by a Domestic Insurer

_______________________________________

(Name of Applicant)

_______________________________________

(Name of Other Person Involved in Merger or Acquisition)

Filed with the Insurance Department of the State of

_______________________

Name, title, mailing address, e-mail address, and telephone number of person completing this statement:

_______________________________________

_______________________________________

_______________________________________

_______________________________________

Item 1. Name and Address.

State the names and addresses of the persons who hereby provide notice of their involvement in a pending acquisition or change in corporate control.

Item 2. Name and Addresses of Affiliated Companies.

State the names and addresses of the persons affiliated with those listed in Item 1. Describe their affiliations.

Item 3. Nature and Purpose of The Proposed Merger or Acquisition. State the nature and purpose of the proposed merger or acquisition.

Item 4. Nature of Business.

State the nature of the business performed by each of the persons identified in response to Item 1 and Item 2.

Item 5. Market and Market Share.

State specifically what market and market share in each relevant insurance market the persons identified in Item 1 and Item 2 currently enjoy in this state. Provide historical market and market share data for each person identified in Item 1 and Item 2 for the past five (5) years and identify the source of such data. Provide a determination as to whether the proposed acquisition or merger, if consummated, would violate the competitive standards of the state as stated in section 382.095.4 of the Act. If the proposed acquisition or merger would violate competitive standards, provide justification of why the acquisition or merger would not substantially lessen competition or create a monopoly in the state.

For purposes of this question, market means direct written insurance premium in this state for a line of business as contained in the annual statement required to be filed by insurers licensed to do business in this state.

Item 6. Signature and Certification.

Signature and certification required as follows:

SIGNATURE

Pursuant to the requirements of sections 382.040.3 and 382.095 of the Act _______________________________________ has caused this application to be duly signed on its behalf in the City of __________________________________ and State of ____________________________ on the __________ day of ______________, ______________.

(SEAL)

__________________________________________

(Name of Applicant)

by

_____________________________ ___________________

(Name)(Title)

Attest:

__________________________________________

(Signature of Officer)

__________________________________________

(Title)

CERTIFICATION

The undersigned deposes and says that s/he has duly executed the attached notice dated _______________, _________________, for and on behalf of ___________________________________ that

(Name of Officer)

s/he is the _____________________________________________ of

(Title of Officer)

__________________________________________

(Name of Company)

and that s/he is authorized to execute and file such instrument. Deponent further says that s/he 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)

FORM F

Enterprise Risk Report

Filed with the Insurance Department of the State of _______________________ by _____________________________

(Name of Registrant/Applicant)

On behalf of/related to the following insurance companies:

Name Address

__________________________________________

__________________________________________

__________________________________________

__________________________________________

Date ____________________, __________

Name, title, mailing address, e-mail address, and telephone number of individual to whom notices and correspondence concerning this statement should be addressed:

__________________________________________

__________________________________________

__________________________________________

Item 1. Enterprise Risk.

(A) Where an insurance holding company system has previously filed the annual group capital calculation at least once, the lead state director has the discretion to exempt the ultimate controlling person from filing the annual group capital calculation if the lead state director makes a determination based upon that filing that the insurance holding company system meets all of the following criteria:

(B) Where an insurance holding company system has previously filed the annual group capital calculation at least once, the lead state director has the discretion to accept in lieu of the group capital calculation a limited group capital filing if-

(C) For an insurance holding company system that has previously met an exemption with respect to the group capital calculation pursuant to subsection (21)(A) or (21)(B) of this rule, the lead state director may require at any time the ultimate controlling person to file an annual group capital calculation, completed in accordance with the NAIC Group Capital Calculation Instructions, if any of the following criteria are met:

(D) A non-U.S. jurisdiction is considered to "recognize and accept" the group capital calculation if it satisfies the following criteria:

(E) A list of non-U.S. jurisdictions that "recognize and accept" the group capital calculation will be published through the NAIC Committee Process:

(F) An insurance company holding system required to file a group capital calculation shall file it on or before August 1 of each year in accordance with section 382.176, RSMo.