North Dakota Administrative Code
Title 45 - Insurance, Commissioner of
Article 45-03 - Regulation of Insurance Companies
Chapter 45-03-05 - Insurance Holding Company System Model Regulation With Reporting Forms and Instructions
Form C - SUMMARY OF CHANGES TO REGISTRATION STATEMENT
Filed with the Insurance Department of the State of ________
BY
___________________________________________
Name of Registrant
On Behalf of the Following Insurance Companies
Name Address
________________________________________________
________________________________________________
________________________________________________
________________________________________________
Date: ___________________ , 20____
Name, title, 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 registration statement. The description shall be in a manner as to permit the proper evaluation thereof by the commissioner, and shall include specific references to item numbers in the annual registration statement and to the terms contained therein.
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 the changes are ones which result in ownership or holdings of ten percent 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 or 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 registration statement has been changed, the nature of the 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 North Dakota Century Code Section 26.1-10-04, the registrant has caused this annual registration statement to be duly signed on its behalf in the City of __________ and State of __________ on the __________ day of __________ , 20 ____.
(SEAL) ____________________________
(Name of Applicant)
By: ___________________________
(Name) (Title)
Attest:
____________________________
(Signature of officer)
____________________________
(Title)
CERTIFICATION
The undersigned deposes and says that the deponent has duly executed the attached annual registration statement dated ________ , 20____, for and on behalf of _______________________ ; that the deponent is the
(Name of company)
___________________________ of the company;
(Title of officer)
and that the deponent is authorized to execute and file the instrument. Deponent further says that deponent is familiar with the instrument and the contents thereof, and that the facts therein set forth are true to the best of deponent's knowledge, information, and belief.
(Signature) _______________________
(Type or print name beneath) _______________________________
