Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-23 - INSURANCE HOLDING COMPANY REGULATIONS › Form (120-2-23) C - SUMMARY OF CHANGES TO REGISTRATION STATEMENT

Current through Rules and Regulations filed through June 27, 2024
Filed with the Insurance Department of the State
				  of______________________
By
____________________________________
Name of Registrant
On Behalf of 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
				  annual 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 such changes are ones which result in
				  ownership or holdings of 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 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 annual
				  registration statement has been changed, the nature of such 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:
Pursuant to the requirements of O.C.G.A. Section
				  33-13-4, Registrant has caused
				  this annual registration statement to be duly signed on its behalf of 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 (s)he has
				  duly executed the attached annual registration statement dated _______________,
				  20_____, for and on behalf of _______________________(Name of Applicant); that
				  (s)he is the ___________________(Title of Officer) of such 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
				  beneath)_______________________________