Illinois Administrative Code › Title 50 - INSURANCE › Part 653 - PRE-ACQUISITION NOTIFICATION › ILLUSTRATION A - Form CX

Current through Register Vol. 48, No. 28, July 12, 2024
INSTRUCTIONS FOR COMPLETION
FORM CX
PRE-ACQUISITION NOTIFICATION
Filed with the Insurance Department of the State
				of Illinois.
BY
__________________________
(Name of Registrant)
On Behalf of the Following Insurance Companies
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Date: ___________ , 20 _______
Name, Title and Address of Officer to Whom Notices and
				Correspondence Concerning this Statement Should be Addressed:
				___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Item 1. Parties.
Identify all "involved insurers", "acquired persons" or
				"acquired insurers" subject to Section 131.12 a of the Illinois Insurance
				Code.
Item 2. Method and
			 Date of Acquisition.
Describe the transactions that will occur and may directly or
				indirectly change the control, as defined in Code Section 131.1(b), of an
				insurer authorized to do business in this State. Identify the effective date
				for the transactions.
Item
			 3. Market Shares.
Identify the rank and percent of the market share for each
				insurer or group of insurers as defined by Code Section 131.12a by line of
				insurance. The lines of insurance include Illinois business reported on the
				Direct Business In The State Of Illinois page of the Life, Accident and Health
				Annual Statement blank and the Exhibit of Premiums and Losses (Statutory Page
				14) page of the Property and Casualty Annual Statement blank as filed with the
				Director for the preceding year as required by Code Section
				136.
Item 4. Expert Opinion
			 (Optional).
Include statement by economist regarding competitive impact of
				acquisition. The statement shall also include the qualifications of that
				economist.
Item 5. Filing
			 Fees.
Pursuant to Code Section 408, the Director shall collect a fee
				for the filing of a statement of acquisition of a foreign or alien insurance
				company. This filing shall not be deemed complete until the Director has
				received the appropriate filing fee required by Section 408.
Item 6. This Form is not to be used as a
			 blank form to be filled in, but only as a guide in the preparation of the
			 statement.
Item 7. Incorporation by
			 Reference
a) Materials required by any item of
			 this statement may be incorporated by reference in answer or partial answer to
			 any other item.
b) Information
			 contained in any financial statement, annual report, proxy statement, statement
			 filed with a governmental authority, or any other document may be incorporated
			 by reference in answer or partial answer to any item, provided the document or
			 paper is filed as an exhibit to the statement. Excerpts of documents may be
			 filed as exhibits if the documents are extensive. Documents currently on file
			 with the Director that were filed within the prior three years need not be
			 attached as exhibits. References to information contained in exhibits or in
			 documents already on file shall clearly identify the material and shall
			 specifically indicate that the material is to be incorporated by reference in
			 answer to the item. Material shall not be incorporated by reference in any case
			 in which the incorporation would render the statement incomplete, unclear or
			 confusing.
c) When an item requires
			 a summary or outline of the provisions of any document, only a brief statement
			 shall be made as to the pertinent provisions of the document. In addition to
			 the statement, the summary or outline may incorporate by reference particular
			 parts of any exhibit or document currently on file with the Director that was
			 filed within three years and may be qualified in its entirety by the reference.
			 In any case in which two or more documents required to be filed as exhibits are
			 substantially identical in all material respects except as to the parties, the
			 dates of execution, or other details, a copy of only one of the documents need
			 be filed, with a schedule identifying the omitted documents and setting forth
			 the material details in which the documents differ from the documents a copy of
			 which is filed.
Affidavit of Registrant.
State of
________
)
________
)
County of
________
)
(Company officer) ________________________ being duly sworn,
				deposes and says:
That he is the _____(Title)_____ of the _____(Name of the
				Company)_____, a corporation organized and existing under and by virtue of the
				laws of the State of _____(State)_____; and on whose behalf makes this
				Affidavit.
Deponent says that he is familiar with Pre-Acquisition
				Notification and the contents thereof, and that the facts set forth are true to
				the best of his knowledge, information and belief.
______________________
(Signature)
(Type or Print Name
				Beneath)