Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 7.00 - Massachusetts Insurance Holding Company System › Section 7.13 - Form B Instructions

Current through Register 1525, July 5, 2024
FORM B
INSURANCE HOLDING COMPANY SYSTEM ANNUAL 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:
___________________________________________________________
___________________________________________________________
___________________________________________________________
(1) 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.
(2) 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. No
			 affiliate need be shown if its total assets are equal to less than U of 1% of
			 the total assets of the ultimate controlling person within the insurance
			 holding company system, unless it has assets valued at or exceeding $10
			 million.
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 control. As to each person specified in the chart or listing indicate the
				type of organization (
e.g
., corporation, trust, partnership)
				and the state or other jurisdiction of domicile.
(3) 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.