Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 180 - INSURANCE HOLDING COMPANY SYSTEM MODEL RULE WITH REPORTING FORMS AND INSTRUCTIONS › Form 031-180-C - SUMMARY OF CHANGES TO REGISTRATION STATEMENT

Current through 2024-29, July 17, 2024
Filed with the Bureau of Insurance of the State of
				  Maine
BY
____________________________________
Name of Registrant
On Behalf of the 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 that
				  permits proper evaluation by the Superintendent, and shall include specific
				  references to Item numbers in the annual registration statement and to the
				  terms contained therein.
Changes in the percentage of each class of voting securities
				  held by each affiliate, reportable in Item 2 of Form B, need only be included
				  where such changes result in ownership or holdings of 10 percent or more of
				  voting securities, loss or transfer of control, or acquisition or loss of
				  partnership interest.
Changes reportable in 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
				  a new president or chief executive officer of the ultimate controlling person
				  is named.
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 pending or anticipated 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.
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:
SIGNATURE:
Pursuant to the requirements of 24-A M.R.S.A. § 222(8),
				  the Registrant has caused this summary of changes to registration statement to
				  be duly signed on its behalf in the City of ___________________ and State of
				  _______________________ on the _______________ day of ________________________,
				  20___.
(SEAL) _________________________________________
Name of Registrant
BY ____________________________________________
(Name) (Title)
ATTEST:
_________________________________
(Signature of Officer)
_________________________________
(Title)
CERTIFICATION:
The undersigned deposes and says that (s)he has duly executed
				  the attached summary of changes to registration statement dated
				  _____________________, 20____, for and on behalf of _______________
(Name of Company); that (s)he is the ________________________
				  (Title of Officer) of the Registrant; and that (s)he is authorized to execute
				  and file this instrument.
Deponent further says that (s)he is familiar with this
				  instrument and the contents hereof, and that the facts herein set forth are
				  true to the best of his/her knowledge, information, and belief.
________________________________________________
Signature
________________________________________________
(Type or Print Name)