Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 1 - Regulation Number 31-Holding Company › Section XIII-137 - Form C-Registration Statement Summary

Current through Register Vol. 50, No. 6, June 20, 2024
SUMMARY OF REGISTRATION STATEMENT
Filed with the Insurance Department of the State of
				  _____________________
By
________________________________
(Name of Registrant)
On Behalf of the 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:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
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 percent 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 years 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 RS. 22:691.6, the Registrant
				  has caused this summary of registration statement to be duly signed on its
				  behalf in the City/Parish of ____________________________ and the 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 summary of registration statement dated
				  ________________________ 20 __________, for and on behalf of
				  _________________________ (Name of Company); that (s)he is the
				  __________________________ (Title of Officer) of such company and that (s) he
				  is authorized to execute and file such instrument. Deponent further says that
				  (s) he 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)
				  __________________________
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  22:691.6 and
				  22:691.11.