Mississippi Administrative Code › Title 19 - Department of Insurance › Part 1 - General › Chapter 20 - Insurance Holding Company Regulation with Reporting Forms and Instructions › Rule 19-1-20.26 - Form B - Insurance Holding Company System Annual Registration Statement

Current through June 25, 2024
FORM B
INSURANCE HOLDING COMPANY SYSTEM ANNUAL REGISTRATION
				  STATEMENT
Filed with the Insurance Department of the State of
				  ____________________
BY
__________________________
(Name of Registrant)
On Behalf of Following Insurance Companies:
Name Address
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Date: ________________ , 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, i.e., corporation, partnership, individual, trust,
				etc.
E. The principal business of
				the person.
F. The name and
				address of any person who holds or owns 10% or more of any class of voting
				security, the class of such security, 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 proceedings and the date when
				commenced.