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-A-1 - DISCLAIMER OF CONTROL OR AFFILIATION WITH A MAINE INSURER OR NOTICE OF DIVESTITURE OF CONTROL OR AFFILIATION

Current through 2024-29, July 17, 2024
FILED BY
____________________________________
Name of Applicant
on behalf of
________________________________________________
________________________________________________
________________________________________________
________________________________________________
Name of Disclaiming or Divesting Party and name(s) of any
				  controlled subsidiaries or affiliates of Disclaiming or Divesting Party
regarding control of
__________________________________________________
Name of domestic insurer (the "Subject Insurer")
whose control or affiliation is disclaimed or will be
				  divested
including its following controlled subsidiaries and/or
				  affiliates:
________________________________________________
________________________________________________
________________________________________________
________________________________________________
Filed with the Bureau of Insurance of the State of
				  Maine
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 STATUS OF
				APPLICANT
State whether the applicant is the Disclaiming or Divesting
				  Party, the Subject Insurer, or a representative of one or both of those
				  parties. If the applicant is filing in a representative capacity, explain the
				  applicant's relationship to the party(ies) the applicant represents.
ITEM 2.
PURPOSE OF
				APPLICATION
(a) State whether there is
				a pending or anticipated transaction or event that might affect or be perceived
				as affecting the relationship between the Disclaiming or Divesting Party and
				the Subject Insurer, or whether this application is being filed solely to
				certify that the Disclaiming Party currently does not directly or indirectly
				exercise, have a right to exercise, or intend to exercise control, within the
				meaning of the Maine Holding Company Act, Title 24-A, M.R.S.A., Section 222,
				over the Subject Insurer(s).
(b) If
				this application is filed in whole or part because of some pending or
				anticipated transaction or event, describe that transaction or event, and
				explain whether the applicant represents:
(1)
				that the transaction or event will not cause the Disclaiming Party to acquire
				control or the right or ability to acquire or exercise control over the Subject
				Insurer(s); or
(2) that the
				transaction or event will cause the Divesting Party to lose control, or the
				presumption or inference of control, or the right or ability to acquire or
				exercise control over the Subject Insurer(s).