Illinois Administrative Code › Title 50 - INSURANCE › Part 652 - REGISTRATION OF INSURERS › ILLUSTRATION C - Form C - Summary of Registration Statement

Current through Register Vol. 48, No. 28, July 12, 2024
FORM C
SUMMARY OF CHANGES TO REGISTRATION
				STATEMENT
Filed with the Department
of Insurance of the State of Illinois
By
___________________________________
Name of Registrant
On Behalf of the Following Insurance
				Companies
NameAddress
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Date: ___________,
				20_________________________________________
Name, Title, Address and telephone number of
				Individual to Whom Notices and Correspondence Concerning This Summary Should Be
				Addressed:
__________________________________________________________
__________________________________________________________
__________________________________________________________
Furnish a brief description of all items in the current annual
				registration statement that represent changes from the prior year's annual
				registration statement. The description shall include specific references to
				item numbers in the annual registration statement and to the terms contained in
				the item. Changes occurring under Item 2, insofar as changes in the percentage
				of each class of voting securities held by each affiliate is concerned, need
				only be included if the changes are ones that result in ownership or holdings
				of 10% or more of voting securities, or loss or transfer of control or
				acquisition or loss of partnership interest. Changes occurring under Item 4 of
				the annual registration statement need only be included if: (1) an individual
				is, for the first time, made a director or executive officer of the ultimate
				controlling person or (2) a director or executive officer terminates his or her
				responsibilities with the ultimate controlling person.
If a transaction disclosed on the prior year's annual
				registration statement has been amended, the nature of the amendment shall 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 statements 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, disclosure and the review that might otherwise
				occur pursuant to Section
				131.20 a of the
				Code.
SIGNATURE Signature and certification of the form as
				follows:
SIGNATURE
Pursuant to 50 Ill. Adm. Code
				652.40,
				the Registrant has caused this summary of registration statement to be duly
				signed on its behalf in the City of _______________State of________ on the
				_______day of__________ , 20___.
_____________________________
(Name of Registrant)
_____________________________
(Name)(Title)
Attest:
_____________________
(Signature of Officer)
_____________________
(Title)
CERTIFICATION
The undersigned deposes and says that (s)he has duly executed
				the attached summary of registration statement dated _________________, 20____
				, for and on behalf of ______ (Name of Company)_______; that (s)he is the
				______(Title of Officer)______ of that company, and that (s)he is authorized to
				execute and file the instrument. Deponent further says that (s)he is familiar
				with the instrument and that the facts set forth in the instrument are true to
				the best of his/her knowledge, information and belief.
_____________________________
(Signature)
_____________________________
(Type or Print Name)