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 21.186 - Preacquisition notification; potential competitive impact; Form E

Current through May 31, 2024
A domestic insurer including any person controlling a
					 domestic insurer required to file notice under
					 AS
					 21.22.010, and a nondomiciliary insurer
					 licensed to do business in this state required to file notice under
					 AS
					 21.22.065 of a proposed merger or acquisition
					 shall furnish the required preacquisition notification information on Form E,
					 made a part of this section in substantially the following form:
FORM E
PRE-ACQUISITION NOTIFICATION FORM REGARDING THE POTENTIAL
					 COMPETITIVE IMPACT OF A PROPOSED MERGER OR ACQUISITION BY A NON-DOMICILIARY
					 INSURER DOING BUSINESS IN THIS STATE OR BY A DOMESTIC INSURER
_________________________
(Name of Applicant)
_________________________
(Name of Other Person Involved in Merger or
					 Acquisition)
Filed with the Division/Department of Insurance of the
					 State of _______
Date: ______________, 20 _____
Name, Title, Address, Electronic Mail Address, and
					 Telephone Number of lndividual Completing This Statement:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
ITEM 1. NAME AND ADDRESS
State the name and address of each person identified above
					 who is providing notice of the person's involvement in a pending acquisition or
					 change in corporate control.
ITEM
				  2. NAME AND ADDRESS OF AFFILIATED COMPANIES
State the name and address of each person affiliated with
					 those listed in Item 1. Describe their affiliations. "Affiliated" has the
					 meaning given in
					 AS
					 21.22.200.
ITEM 3. NATURE AND PURPOSE OF THE PROPOSED
				  MERGER OR ACQUISITION
State the nature and purpose of the proposed merger or
					 acquisition.
ITEM 4. NATURE
				  OF BUSINESS
State the nature of the business performed by each person
					 identified in response to Items 1 and 2.
ITEM 5. MARKET AND MARKET SHARE
State specifically what market and market share in each
					 relevant insurance market each person identified in Items 1 and 2 currently
					 experiences in this state. Provide historical market and market share data for
					 each person identified in Items 1 and 2 for the past five years and identify
					 the source of the data. Provide a determination as to whether the proposed
					 acquisition or merger, if consummated, would violate the competitive standards
					 of the state under
					 AS
					 21.22.065( d). If the proposed acquisition or
					 merger would violate competitive standards, provide justification of why the
					 acquisition or merger would not substantially lessen competition or create a
					 monopoly in the state. "Insurance market" has the meaning given in
					 AS
					 21.22.200. Furnish the data and calculations
					 necessary for the director to make a determination under
					 AS
					 21.22.065( d).
Furnish calculations, discussion, or other information that
					 would constitute "other substantial evidence" under
					 AS
					 21.22.065(f) or would
					 provide information supportive of
					 AS
					 21.22.065(g).
Furnish other information pertinent to the approval or
					 pre-approval sought. If a Form A, an application for certificate of authority,
					 or another filing for the company or affiliate of the company is pending before
					 the director, identify and describe the associated filing. Note: The division
					 may additionally choose to make additional calculations under
					 AS
					 21.22.065 using the division's own data or
					 data provided by the National Association of lnsurance
					 Commissioners.
ITEM 6.
				  EXEMPTION FROM
				  AS
				  21.22.065
If a company is claiming an exemption from the requirements
					 of AS
					 21.22.065 under the provisions of
					 AS
					 21.22.065(j)(3), (5), or
					 (7), furnish the relevant data, calculations,
					 discussion, or other information necessary for the director to determine the
					 appropriateness of the exemption.
If a company is claiming an exemption under the provisions
					 of AS
					 21.22.065(j)(5)(A), a letter
					 of pre-notification of acquisition may be submitted in lieu of a completed Form
					 E.
ITEM 7. SIGNATURE AND
				  CERTIFICATION
Signature and certification are required as follows:
SIGNATURE
Under the requirements of
					 AS
					 21.22.065, ______ has caused this notice to
					 be signed on its behalf in the City or Community 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 the undersigned has
					 duly executed the attached notice dated ________________, 20 _____, for and on
					 behalf of ____________________(Name of Applicant); 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 21.22.065
AS 21.22.130
AS
						21.22.200