Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 7.00 - Massachusetts Insurance Holding Company System › Section 7.14 - Form C Instructions

Current through Register 1525, July 5, 2024
FORM C
SUMMARY OF REGISTRATION STATEMENT
Filed with the Division of Insurance of the Commonwealth of
				Massachusetts
By
___________________________
Name of Registrant
On Behalf of Following Insurance Companies
Name Address
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Date:________________, 20______
Name, title, address, telephone number, and email 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 as to permit the
				proper evaluation thereof by the Commissioner, and shall include specific
				references to Item numbers in the annual registration statement and to the
				terms contained therein.
Changes occurring under Item 2 of Form B insofar as changes in
				the percentage of each class of voting securities held by each affiliate is
				concerned, need only be included where such changes are ones which result in
				ownership or holdings of 10% or more of voting securities, loss or transfer of
				control, or acquisition or loss of partnership interest.
Changes occurring under 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
				in the event an individual is named president of the ultimate controlling
				person.
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 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.
The insurer shall 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 M.G.L. c. 175, § 206C and
				211
				CMR 7.06(2), the Registrant
				has caused this annual registration statement 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 he or she has duly
				executed the attached annual registration statement dated
				_______________________, 20 _______, for and on behalf of
_______________________________; that he or she is
				the____________________________
(Name of Company) (Title of Officer)
of such company and that (s)he is authorized to such execute
				and file instrument. Deponent further says that he or she is familiar with such
				instrument and the contents thereof, and that the facts therein set forth are
				true to the best of his/her knowledge, information and belief.
(Signature)__________________________________________________________________
(Type or print name
				beneath)______________________________________________