Alaska Administrative Code › Title 3 - Commerce, Community, and Economic Development › Part 2 - Division of Insurance › Chapter 21 - Insurer - Financial › Article 1 - Insurance Holding Companies › 3 AAC 21.180 - Summary of registration statement filing; Form C

Current through May 31, 2024
An insurer required to file a statement under
					 AS
					 21.22.060 shall also furnish the required
					 information on Form C, made a part of this section in substantially the
					 following form:
FORM C
SUMMARY OF CHANGES TO REGISTRATION STATEMENT
Filed with the Insurance Division/Department of the State
					 of _________
By
_________________
(Name of Registrant)
On Behalf of the Following Insurance Companies
Name Address
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Date: ______________, 20 _____
Name, Title, Address, Electronic Mail Address, and
					 Telephone Number of lndividual to Whom Notices and Correspondence Concerning
					 This Statement Should be Addressed:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Furnish a brief description of all items in the current
					 registration statement that represent changes from the most recently filed
					 registration statement. The description must be in a manner to permit the
					 proper evaluation by the director, and must include specific references to item
					 numbers in the annual registration statement and to the terms contained in
					 it.
Changes occurring under Item 2 of Form B, to the extent
					 that changes in the percentage of each class of voting securities held by each
					 affiliate are concerned, need only be included where the changes are ones that
					 result in ownership or holdings of 10 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 when an individual is made a director or executive officer of the
					 ultimate controlling person for the first time; a director's or executive
					 officer's responsibilities for the ultimate controlling person are terminated;
					 or an individual is named president, chief executive officer, treasurer, or
					 chief financial officer of the ultimate controlling person.
If a transaction disclosed on the prior year's annual
					 registration statement has been changed, the nature of the change must be
					 included. If a transaction disclosed on the prior year's annual registration
					 statement has been completed, furnish the mode of completion and any flow of
					 funds between affiliates resulting from the transaction.
The insurer shall furnish a statement affirming that
					 transactions entered into since the filing of the prior registration statement
					 are not part of a plan or series of like transactions the purpose of which is
					 to avoid statutory threshold amounts and the review that might otherwise
					 occur.
SIGNATURE AND CERTIFICATION
Signature and certification are required as follows:
SIGNATURE
Under
					 AS
					 21.22.060, the registrant has caused this
					 summary of changes to registration statement to be signed on its behalf in the
					 City or Community of ____________ and State of ____________, on the day of
					 ____________, 20____.
(SEAL)
____________________
(Name of Registrant)
By ___________
(Name) (Title)
Attest:
____________________
(Signature of Officer)
____________________
(Title)
CERTIFICATION
The undersigned deposes and says that the undersigned has
					 duly executed the attached summary of registration statement dated
					 ____________, 20 ____, for and on behalf of __________________(Name of
					 Company); that the undersigned is the _____________(Title of Officer) of the
					 company; and that the undersigned is authorized to execute and file the
					 instrument. The undersigned further says that the undersigned is familiar with
					 the instrument and the contents of it and that the facts stated in it are true
					 to the best of the undersigned's knowledge, information, and belief.
(Signature)
_______________________
(Type or print name below)
______________________
Authority:
AS
						21.06.090
AS 21.22.060
AS
						21.22.130