Illinois Administrative Code › Title 50 - INSURANCE › Part 655 - PRIOR NOTIFICATION OF DIVIDENDS ON COMMON STOCK AND OTHER DISTRIBUTIONS › ILLUSTRATION A - Form D-2

Current through Register Vol. 48, No. 28, July 12, 2024
FORM D-2
GENERAL INSTRUCTIONS
Signature and Certification.
For purposes of filing the Form D-2, the signature and
				certification required by this Part shall be signed by an executive officer of
				the insurer.
PRIOR NOTICE OF DIVIDENDS ON COMMON
STOCK AND OTHER DISTRIBUTIONS
Filed with the Illinois Department of Insurance
By
____________________________________
Name of Domestic Company
On behalf of the Following Insurance Companies:
NameAddress
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Date __________, 20___
Name, Title, Address and Telephone Number of the Individual to
				Whom Notices and Correspondence Concerning this Request Should be
				Addressed:
______________________________________________________________
______________________________________________________________
______________________________________________________________
Item 1. Type of Dividend or Distribution.
Identify the dividend or distribution as a dividend or other
				distribution subject to Code Section 131.16 or as an extraordinary dividend or
				other extraordinary distribution as defined in Code Section
				131.20
				a(2).
Item 2. The amount of
			 the dividend or other distribution and the date established for payment. The
			 proposed date must be consistent with requirements for receipt of notice by the
			 Department, as specified in Section
			 655.30(a).
Item 3. A statement as to whether the
			 dividend or other distribution is to be in cash or other property, and, if in
			 property, a description of the property, its cost, statutory carrying value,
			 and the fair market value of the property, together with an explanation of the
			 basis for valuation.
Item 4. The
			 amounts and payment dates of all dividends paid within the period of 12
			 consecutive months ending on the date fixed for payment of the proposed
			 dividend for which notification is being given or approval is being
			 sought.
Item 5. An illustration of
			 the calculation of the extraordinary dividend limit set by Code Section
			 131.20a. Dividends that have been or will be paid in other than cash shall be
			 valued for the purposes of the calculation at the greater of market or
			 statutory carrying value of the asset.
Item
			 6. If the notice is filed for an extraordinary dividend pursuant
			 to Code Section 131.20a, the following items must also be included:
a) A balance sheet and statement of income
			 for the period intervening from the last annual statement filed with the
			 Director and the end of the month preceding the month in which the prior
			 notification of the dividend is submitted. Indicate the amount of all
			 unrealized capital gains included in unassigned funds.
b) A brief statement as to the effect of the
			 proposed dividend upon the insurer's surplus and the reasonableness of surplus
			 in relation to the insurer's outstanding liabilities and the adequacy of
			 surplus relative to the insurer's financial position.
c) A calculation of the insurer's risk based
			 capital level as of the most recently filed financial statement (quarterly or
			 annual), adjusted to show the effect of the proposed dividend or other
			 distribution.
Pursuant to the requirements of Code Section 131.16 (or
				Sections 131.6 and 131.20a, in the case of extraordinary dividends),
				______________ has caused this notice to be duly signed on its behalf in the
				City of _______________________ and State of ________ on the ________ day of
				________, 20 __.
_____________________________
Name of Requesting Insurer
By
_____________________________
Type or print
_____________________________
(Name)(Title)
Attest:
____________________
(Signature of Officer)
____________________
(Title)
CERTIFICATION
The undersigned deposes and says that he or she had duly
				executed the attached notice dated ______________ , 20 ______, for and on
				behalf of _________(Name of Insurer)_________, that he or she is the
				__________(Title of Officer)___________ of the company and that he or she is
				familiar of the company and that he or she is familiar with the instrument and
				its contents, and that the facts set forth in that instrument are true to the
				best of his or her knowledge, information and belief.
(Signature)
___________________
(Type or print name beneath)
___________________