Administrative Rules of Montana › Department 6 - STATE AUDITOR › Chapter 6.6 - INSURANCE DEPARTMENT › Subchapter 6.6.37 - Reporting by Holding Company Systems › Rule 6.6.3717 - FORMS

Current through Register Vol. 13, July 5, 2024
(1) The following
				forms apply to this subchapter.
(a)
FORM
				A
STATEMENT REGARDING THE
ACQUISITION OF CONTROL OF OR MERGER WITH A DOMESTIC
				  INSURER
Name of Domestic Insurer
BY
_________________________________
Name of Acquiring Person (Applicant)
Filed with the Office of the Montana State Auditor,
				  Commissioner of Securities and Insurance
______________________________________________________________
(State of domicile of insurer being acquired)
Dated: _______________, 20____
Name, Title, Address, and Telephone Number of Individual to
				  Whom Notices and Correspondence Concerning this Statement Should be Addressed:
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Items 1 through 13 remain the same.
(b)
FORM B
INSURANCE HOLDING COMPANY SYSTEM ANNUAL REGISTRATION
				  STATEMENT
Filed with the Office of the Montana State Auditor,
				  Commissioner of Securities and Insurance
By
________________________________
Name of Registrant
On Behalf of 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:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Items 1 through 10 remain the same.
(c)
FORM C
SUMMARY OF CHANGES TO REGISTRATION
				  STATEMENT
Filed with the Office of the Montana State Auditor,
				  Commissioner of Securities and Insurance
By
_______________________________
Name of Registrant
On Behalf of 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 must be in a manner as to permit
				  the proper evaluation thereof by the commissioner, and must 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 must 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 must 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 the purpose of which is
				  to avoid statutory threshold amounts and the review that might otherwise
				  occur.
SIGNATURE AND CERTIFICATION
Signature and certification required as follows:
Pursuant to the requirements of
				  33-2-1111, MCA, the registrant has
				  caused this summary of registration statement to be duly signed on its behalf
				  in the city of _____________ and state of ________________ on the_______ day of
				  _____________, 20___.
(SEAL) _________________________
Name of Registrant
By _________________________
(Name)
(Title)
Attest:
_______________________
(Signature of Officer)
_______________________
(Title)
CERTIFICATION
The undersigned certifies that (s)he has duly executed the
				  attached summary of registration statement dated __________________, 20__, for
				  and on behalf of ______________________ (Name of Applicant); 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)
				  ________________________
(d)
FORM D
PRIOR NOTICE OF A TRANSACTION
Filed with the Office of the Montana State Auditor,
				  Commissioner of Securities and Insurance
By
_________________________________
Name of Registrant
On Behalf of 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:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Items 1 through 7 remain the same.
(e)
FORM F
ENTERPRISE RISK REPORT
Filed with the Office of the Montana State Auditor,
				  Commissioner of Securities and Insurance
By
..................................................................
Name of Registrant/Applicant
On Behalf of/Related to 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:
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
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
				  33-2-1101(3),
				  MCA, provided such information is not disclosed in the Insurance Holding
				  Company System Annual Registration Statement filed on behalf of itself or
				  another insurer for which it is the ultimate controlling person:
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
				  reallocating 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 (10%) or more 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 next 12 months;
Identification of material concerns of the insurance holding
				  company system raised by supervisory college, if any, in 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 assessment of 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 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 attach the appropriate form most
				  recently filed with the U.S. Securities and Exchange Commission, provided the
				  Registrant/Applicant includes specific references to those areas listed in Item
				  1 for which the form provides responsive information. If the
				  Registrant/Applicant is not domiciled in the U.S., it may attach its most
				  recent public audited financial statement filed in its country of domicile,
				  provided the Registrant/Applicant includes specific references to those areas
				  listed in Item 1 for which the financial statement 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.