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-B - INSURANCE HOLDING COMPANY SYSTEM ANNUAL 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:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
ITEM 1.
IDENTITY AND CONTROL OF
				REGISTRANT
Furnish the exact name of each insurer registering or being
				  registered (hereinafter called "the Registrant"); the home office address and
				  principal executive offices of each; the date on which each Registrant became
				  part of the insurance holding company system; and the method(s) by which
				  control of each Registrant was acquired and is maintained.
ITEM 2.
ORGANIZATIONAL CHART
Furnish a chart or listing clearly presenting the identities
				  of and interrelationships among all affiliated persons within the insurance
				  holding company system. The chart or listing should show the percentage of each
				  class of voting securities of each affiliate which is owned, directly or
				  indirectly, by another affiliate. If control of any person within the system is
				  maintained other than by the ownership or control of voting securities,
				  indicate the basis of such control. As to each person specified in such chart
				  or listing indicate the type of organization (
e.g.,
corporation, trust, partnership) and the state or other jurisdiction of
				  domicile.
ITEM 3.
THE
				ULTIMATE CONTROLLING PERSON
As to the ultimate controlling person in the insurance
				  holding company system, furnish the following information:
(a) Name.
(b) Home office address.
(c) Principal executive office
				address.
(d) The organizational
				structure of the person,
e.g.,
corporation, partnership,
				individual, trust.
(e) The
				principal business of the person.
(f) The name and address of any person who
				holds or owns 10 percent or more of any class of voting security, the class of
				such security held or owned, the number of shares held of record or known to be
				beneficially owned, and the percentage of class so held or owned.
(g) If court proceedings involving a
				reorganization or liquidation are pending, indicate the title and location of
				the court, the nature of the proceedings, and the date when
				commenced.