Nebraska Administrative Code › Topic - INSURANCE, DEPARTMENT OF › Title 210 - NEBRASKA DEPARTMENT OF INSURANCE › Chapter 24 - HOLDING COMPANIES › Form C - SUMMARY OF REGISTRATION STATEMENT

Current through June 17, 2024
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 represents 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 Director, 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 year's annual registration statement
				  are not part of a plan or series of like transactions whose purpose is to avoid
				  statutory threshold amounts and the review that might otherwise occur.
SIGNATURE AND CERTIFICATION
Pursuant to the requirements of §
									44-2132(3)
				   and 210 Neb. Admin. R. & Regs. 24, 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 deposes and says that (s)he has duly executed
				  the attached summary of registration statement dated_____________, 20_________,
				  for and on behalf of__________, that (s)he is the_______________ of such (Name
				  of Company) (Title of Officer) 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 that the contents thereof, and that the facts therein set
				  forth are true to the best of his/her knowledge, information and belief.