A. Use and time of filing.
11 NYCRR Part 80-1 (Insurance Regulation 52) adopted pursuant to the provisions
of section 1503, prescribes the use of Registration Statement HC 1 for filing
by a controlled insurer.
B.
Formal requirements.
(a) A
registrant shall file electronically a registration statement and any amendment
thereto. The registration statement shall be signed in the name of the
registrant and shall be verified by the officer or agent executing the
same.
(b) The registrant shall
submit a registration statement and amendments thereto to the New York State
Department of Financial Services in New York City.
C.
Incorporation by
reference.
(a) Except as otherwise
specifically provided, the provisions of Insurance Law section 1508 shall
govern incorporation by reference. Where any other controlled insurer within
the registrant's holding company system has filed a registration statement it
may be convenient and desirable for the registrant to refer to answers
contained in such statement. In such cases, the registrant may state that such
reference shall be deemed to refer to any and all amendments of such items or
exhibits thus referred to that may thereafter be filed by such controlled
insurer and, if such statement is made, it shall be deemed to include all
future amendments to the particular item or exhibit to which reference is made.
If such a statement is not made, the incorporation by reference shall be deemed
to refer only to the specific item or exhibit referred to as in effect at the
date the statement making such incorporation by reference is filed.
(b) The registrant shall file a definitive
exhibit and a complete statement in answer to any item if the superintendent
requires such a filing because the incorporation by reference of such exhibit,
or of all or part of the answer to such item, is not responsive to the item
requested.
D.
Availability of information. If the information called for by
any item or exhibit of this form is not known to the registrant, it need give
only such information as can be procured without incurring unreasonable effort
or expense; provided, however, that in every case the answer shall:
(a) clearly and specifically indicate what
part of the information supplied is not definitely known to the registrant and
allege that the statements made represent the registrant's best information and
belief;
(b) adequately disclose the
sources from which the registrant has procured the information given;
and
(c)
(1) state specifically that unreasonable
effort or expense would be involved in procuring more accurate information and
provide reasons to support the assertion; or
(2) make a statement showing that the
required information is within the knowledge of another person, provided that
the statement shall also show that the registrant has made appropriate requests
to such person for the desired information and shall set forth the results of
such requests or efforts.
REQUIRED INFORMATION
Item 1. Specify exact name of
registrant.
Item 2. Specify address
and principal executive offices.
Item
3. Specify date on which registrant became a controlled insurer of
its ultimate holding company, and all methods by which control was acquired and
is maintained.
Item 4.
(a) Furnish a chart that clearly presents the
identities of and interrelationships among, the ultimate holding company and
all controlled persons and controlled insurers within registrant's holding
company system. Indicate in such chart the percentage of voting securities of
each such person that is owned or controlled by the ultimate holding company or
by any other controlled person or controlled insurer within the system. If
control of any person within the system is maintained other than by the
ownership or control of voting securities, then indicate the basis of such
control. As to each person specified in such chart indicate the type of
organization (e.g., corporation, trust, partnership) and the State or other
jurisdiction of domicile.
(b) If
court proceedings looking toward a reorganization or liquidation are pending
with respect to any such person, indicate which person, and set forth the title
of the court, nature of proceedings and the date when commenced.
Item 5. Principal
shareholders of persons within holding company system. As of a date not more
than six months prior to registration (indicating such date for each class),
give the following information with respect to each person who owns of record,
or is known by the registrant to own beneficially, ten percent or more of any
class of equity security of any person within the holding company system; any
such ownership reflected in answer to item 4 need not be restated:
(a) Class of security;
(b) Holder of record and address; and
beneficial owner (if not the holder of record) and address;
(c) Number of shares held of record or known
to be beneficially owned; and
(d)
Percentage of class so held or owned.
Item 6. Business activities. Describe briefly
the general character and principal locations of the business done by the
ultimate holding company and the persons identified under item 4 as being
within the holding company system.
Item
7. Officers and directors. Give the name and business address of
each director and executive officer of the ultimate holding company. For each
such individual give the title of every position held by him or her with
significant persons within the holding company system.
Item 8. Articles of incorporation. With
respect to the ultimate holding company, furnish a copy of the charter,
articles of incorporation, trust agreement, voting trust agreement, or other
fundamental document of organization, and a copy of its by-laws or other
instruments corresponding thereto. Each such document shall be in the amended
form effective at the date of filing the registration statement or shall be
accompanied by copies of any amendments to it then in effect.
Item 9. Submit a statement that the
registrant's board of directors, or a committee thereof, oversees corporate
governance and internal controls and that the registrant's officers or senior
management have approved or devised, implemented, and continue to maintain and
monitor corporate governance and internal control procedures.
This registration statement comprises:
(a) Pages numbered ____ to ____,
consecutively.
(b) The following
Exhibits:
SIGNATURE
Pursuant to the requirements of New York Insurance Law
section 1503 and 11 NYCRR Part 80-1 (Insurance Regulation 52) the registrant
has caused this registration statement to be duly signed on its behalf in the
City of _and State of_, on the_day of _, 20
By (Name) (Title)
Attest:
(Signature of Officer)
(Title)
CERTIFICATION
The undersigned deposes and says that she/he has duly
executed the attached registration statement dated_, 20_, for and on behalf of
(Name of Company); that she/he is the(Title of Officer) of
such company; and that all action by directors and other
bodies necessary to authorize deponent to execute and file such instrument has
been taken. Deponent further says that she/he is familiar with such instrument
and that the facts therein set forth are true to the best of her/his knowledge,
information and belief.
Dated:
