Illinois Administrative Code › Title 50 - INSURANCE › Part 204 - INSIDER TRADING OF DOMESTIC STOCK INSURANCE COMPANY EQUITY SECURITIES › Exhibit B - Statement of Changes in Beneficial Ownership of Securities

Current through Register Vol. 48, No. 28, July 12, 2024
STATE OF ILLINOIS
Director of Insurance
Form 2 - Statement of Changes in Beneficial
				Ownership of Securities
Filed pursuant to Section 28.1 of the Illinois
				Insurance Code
_________________________________________________________________
(Name of insurance company)
_________________________________________________________________
(Name of person whose ownership is
				reported)
_________________________________________________________________
(Business address of such person; street, city,
				zone, state)
Relationship of such person to company named above. (See
				instruction 5) ________
Statement for Calendar Month of
				____________________, 19_____
CHANGES DURING MONTH AND MONTH-END OWNERSHIP
				(See instruction 6)
_________________________________________________________________
_________________________________________________________________
Title of Security
Date of Transaction
Amount Bought or Otherwise
						  Acquired
Amount sold or Otherwise Disposed
						  of
Nature of Ownership
Amount Owned Beneficially at End of
						  Month
(See Instruction 7)
(See Instruction 8)
(See Instruction 9)
(See Instruction 10)
(See Instruction 10)
(See Instruction 9)
_________________________________________________________________
REMARKS: (See instruction 11)
Subscribed and sworn to before me this ____ day of
				______________ A.D., 19___.
ILLINOIS DEPARTMENTAL REGULATIONS
STATE OF ILLINOIS
Director of Insurance
Form 2- Instructions for Statement of Changes in Beneficial
				Ownership of Securities
1. Persons
			 Required to File Statements.
Statements on this form are required to be filed by every
				person who at any time during any calendar month was directly or indirectly the
				beneficial owner of more than 10 percent of any class of equity security of an
				Illinois stock insurance company, or a director or officer of the company which
				is the issuer of such securities, and who during such month had any change in
				his beneficial ownership of any class of equity security of such
				company.
2. When Statements
			 Are to Be Filed.
Statements are required to be filed on or before the
				10th day after the end of each month in which any
				change in beneficial ownership has occurred. Statements are not deemed to have
				been filed with the Director until they have actually been received by
				him.
3. Where Statements
			 Are to Be Filed.
4. One signed,
			 sworn true copy of each statement shall be filed with the Director of
			 Insurance, State of Illinois, Springfield, Illinois 62767.
Separate Statement For Each Company.
5. A separate statement shall be filed with
			 respect to the securities of each company.
Relationship of Reporting Person to Company.
Indicate clearly the relationship of the reporting person to
				the company; for example, "Director", "Director and Vice President",
				"Beneficial owner of more than 10 percent of the company's common stock",
				etc.
6. Transactions and
			 Holdings to Be Reported.
Every transaction shall be reported even though purchases and
				sales during the month are equal or the change involves only the nature of
				ownership; for example, from direct to indirect ownership. Beneficial ownership
				at the end of the month of all classes of securities required to be reported
				shall be shown even though there has been no change during the month in the
				ownership of securities of one or more classes.
7. Title of Security.
The statement of the title of the security shall be such as
				clearly to identify the security even though there may be only one class; for
				example, "Class A Common Stock", "5% Debentures Due 1965", etc.
8. Date of Transaction.
The exact date (month, day and year) of each transaction shall
				be stated opposite the amount involved in the transaction.
9. Statements of Amounts of Securities.
In stating the amount of the securities acquired, disposed of,
				or beneficially owned, give the face amount of debt securities or the number of
				shares or other units of other securities. In the case of securities owned
				indirectly, i.e., through a partnership, corporation, trust or other entity,
				the entire amount of securities involved in the transaction or owned by the
				partnership, corporation, trust or other entity shall be stated. The person
				whose ownership is reported may, if he so desires, also indicate in a footnote,
				or other appropriate manner, the extent of his interest in the transaction or
				holdings of the partnership, corporation, trust or other entity.
10. Nature of Ownership.
Under "Nature of ownership", state whether ownership of the
				securities is "direct" or "indirect". If the ownership is indirect, i.e.,
				through a partnership, corporation, trust or other entity, indicate in a
				footnote, or other appropriate manner, the name or identity of the medium
				through which the securities are indirectly owned. The fact that securities are
				held in the name of the broker or other nominee does not, of itself, constitute
				indirect ownership. Securities owned indirectly shall be reported on separate
				lines from those owned directly and from those owned through a different type
				of indirect ownership.
11.
			 Character of Transaction.
If the transaction was with the issuer of the securities, so
				state. If it involved the purchase of securities through the exercise of
				options, so state and give the exercise price per share. If any other purchase
				or sale was effected otherwise than in the open market, that fact shall be
				indicated. If the transaction was not a purchase or sale, indicated its
				character; for example, gift, 5% stock dividend, etc. as the case may be. The
				foregoing information may be appropriately set forth in the table or under
				"Remarks" at the end of the table.
12. Inclusion of Additional Information.
A statement may include any additional information or
				explanation deemed relevant by the person filing the statement.
13. Signature.
If the statement is filed for a corporation, partnership,
				trust, etc., the name of the organization shall appear over the signature of
				the officer or other person authorized to sign the statement. If the statement
				is filed for an individual, it shall be signed by him or specifically on is
				behalf by a person authorized to sign for him.
In those cases where the statement is signed by someone other
				than the person whose ownership is being reported, documentary evidence of the
				signing authority shall be filed with the statement.
In all cases the signature must be duly
				notarized.