Current through Register Vol. 41, No. 3, September 23, 2024
Item 1. Insurer. State the name and address of the
insurer.
Item 2. Identity and Background.
1. State the following:
a. Your name and business address.
b. Your present principal occupation or
employment and the name, principal business and address of any corporation or
other organization in which such employment is carried on.
2. State the following:
a. Your residence address.
b. Information as to all material
occupations, positions, offices or employments during the last 10 years, giving
starting and ending dates of each and the name, principal business and address
of any business corporation or other business organization in which each such
occupation, position, office or employment was carried on.
3. State whether or not you are or have been
a participant in any other proxy contest involving this company or other
companies within the past 10 years. If so, identify the principals, the subject
matter and your relationship to the parties and the outcome.
4. State whether or not, during the past ten
years, you have been convicted in a criminal proceeding (excluding traffic
violations or similar misdemeanors) and, if so, give dates, nature of
conviction, name and location of court, and penalty imposed or other
disposition of the case. A negative answer to this sub-item need not be
included in the proxy statement or other proxy soliciting material.
Item 3. Interest in Securities of the Insurer.
1. State the amount of each class of
securities of the insurer which you own beneficially, directly or
indirectly.
2. State the amount of
each class of securities of the insurer which you own of record but not
beneficially.
3. State with respect
to all securities of the insurer purchased or sold within the past two years,
the dates on which they were purchased or sold and the amount purchased or sold
on each such date.
4. If any part
of the purchase price or market value of any of the securities specified in
subdivision 3 is represented by funds borrowed or otherwise obtained for the
purpose of acquiring or holding such securities, so state and indicate the
amount of the indebtedness as of the latest practicable date. If such funds
were borrowed or obtained otherwise than pursuant to a margin account or bank
loan in the regular course of business of a bank, broker or dealer, briefly
describe the transaction, and state the names of the parties.
5. State whether or not you are a party to
any contracts, arrangements or understandings with any person with respect to
any securities of the insurer, including but not limited to joint ventures,
loan or option arrangements, puts or calls, guarantees against losses or
guarantees of profits, division of losses or profits, or the giving or
withholding of proxies. If so, name the persons with whom such contracts,
arrangements, or understandings exist and give the details thereof.
6. State the amount of securities of the
insurer owned beneficially, directly or indirectly, by each of your associates
and the name and addresses of each such associate.
7. State the amount of each class of
securities of any parent, subsidiary or affiliate of the insurer which you own
beneficially, directly or indirectly.
Item 4. Further Matters.
1. Describe the time and circumstances under
which you became a participant in the solicitation and state the nature and
extent of your activities or proposed activities as a participant.
2. Describe briefly, and where practicable
state the approximate amount of, any material interest, direct or indirect, of
yourself and of each of your associates in any material transactions since the
beginning of the company's last fiscal year, or in any material proposed
transactions, to which the company or any of its subsidiaries or affiliates was
or is to be a party.
3. State
whether or not you or any of your associates have any arrangement or
understanding with any person:
a. With respect
to any future employment by the insurer or its subsidiaries or affiliates;
or
b. With respect to any future
transactions to which the insurer or any of its subsidiaries or affiliates will
or may be a party.
If so, describe such arrangement or understanding and state
the names of the parties thereto.
Item 5. Signature. The statement shall be dated and signed in
the following manner:
I certify that the statements made in this statement are
true, complete, and correct, to the best of my knowledge and belief.
__________ (Date)
__________ (Signature of participant or authorized
representative)
