Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 14 - INSURANCE HOLDING COMPANY › Appendix C - Form C - Summary of Changes to Registration Statement

Current through Register Vol. 30, No. 28, July 12, 2024
SUMMARY OF CHANGES TO REGISTRATION
				  STATEMENT
Filed with the Arizona Department of Insurance and Financial
				  Institutions
By
__________________
[Name of Registrant]
On Behalf of Following Insurance Companies
Name Address
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Dated:_________, 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 Director, 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 A.R.S. §
									20-481.09, Registrant
				  ______________________________has caused this annual registration statement to
				  be duly signed on its behalf in 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 they have duly executed
				  the attached annual registration statement dated _______________, 20_____, for
				  and on behalf of ______________________________; that they are the
				  ___________________ (Name of Applicant)
(Title of Officer)
of such company and that they are authorized to execute and
				  file such instrument. Deponent further says that they are familiar with the
				  instrument and the contents thereof, and that the facts therein set forth are
				  true to the best of their knowledge, information and belief.
_______________________
(Signature)
_______________________
(Type or print name beneath)