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-F - ENTERPRISE RISK REPORT

Current through 2024-29, July 17, 2024
Filed with the Bureau of Insurance of the State of
				  Maine
BY
____________________________________
Name of Registrant/Applicant
On Behalf/ Related to 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.
ENTERPRISE RISK
The Registrant/Applicant, to the best of its knowledge and
				  belief, shall provide information regarding the following areas that could
				  produce enterprise risk as defined in 24-A M.R.S.A. § 222(2) (B-2). If
				  relevant information has been disclosed in the Insurance Holding Company System
				  Annual Registration Statement (Form B) filed on behalf of itself or another
				  insurer for which it is the ultimate controlling person, such information may
				  simply be referenced here in lieu of making a duplicative filing:
* Any material developments regarding strategy, internal
				  audit findings, compliance, or risk management affecting the insurance holding
				  company system;
* Acquisition or disposal of insurance entities and
				  reallocation of existing financial or insurance entities within the insurance
				  holding company system;
* Any changes of shareholders of the insurance holding
				  company system exceeding ten percent of voting securities;
* Developments in various investigations, regulatory
				  activities, or litigation that may have a significant bearing or impact on the
				  insurance holding company system;
* Business plan of the insurance holding company system and
				  summarized strategies for the next 12 months;
* Identification of material concerns of the insurance
				  holding company system raised by a supervisory college, if any, in the last
				  year;
* Identification of insurance holding company system capital
				  resources and material distribution patterns;
* Identification of any negative movement, or discussions
				  with rating agencies which may have caused or may cause potential negative
				  movement, in the credit ratings and individual insurer financial strength
				  ratings assessments of and within the insurance holding company system
				  (including both the rating score and outlook);
* Information on corporate or parental guarantees throughout
				  the holding company and the expected source of liquidity should such guarantees
				  be called upon; and
* Identification of any other material activity or
				  development of the insurance holding company system that, in the opinion of
				  senior management, could adversely affect the insurance holding company system.
The Registrant/Applicant may respond to the extent relevant
				  by attaching the appropriate form most recently filed with the United States
				  Securities and Exchange Commission, or its most recent public audited financial
				  statement filed in its country of domicile if that country is not the United
				  States, provided that the Registrant/Applicant includes specific references to
				  those areas listed in Item 1 for which the form provides responsive
				  information.
ITEM 2.
OBLIGATION TO REPORT
If the Registrant/Applicant has not disclosed any information
				  pursuant to Item 1, the Registrant/Applicant shall include a statement
				  affirming that, to the best of its knowledge and belief, it has not identified
				  enterprise risk subject to disclosure pursuant to Item 1.
ITEM 3.
SIGNATURE AND
				CERTIFICATION
Signature and certification required as follows:
SIGNATURE:
Pursuant to the requirements of 24-A M.R.S.A. § 222 and
				  Bureau of Insurance Rule 180, ___________________ has caused this application
				  to be duly signed on its behalf in the City 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 (s)he has duly executed
				  the attached application dated _______________, 20___, for and on behalf of
				  ___________________ (Name of Applicant); that (s)he is the
				  _____________________________ (Title of Officer) of the Applicant; 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)