North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-03 - Regulation of Insurance Companies › Chapter 45-03-05 - Insurance Holding Company System Model Regulation With Reporting Forms and Instructions › Form C - SUMMARY OF CHANGES TO REGISTRATION STATEMENT

Current through Supplement No. 393, July, 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 represent changes from the prior year's
				  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 the changes are ones which result in
				  ownership or holdings of ten 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 registration
				  statement has been changed, the nature of the 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 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 North Dakota Century Code
				  Section 26.1-10-04, the registrant has caused this annual registration
				  statement to be duly signed on its behalf in the City of __________ and 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 the deponent has duly
				  executed the attached annual registration statement dated ________ , 20____,
				  for and on behalf of _______________________ ; that the deponent is the
(Name of company)
___________________________ of the company;
(Title of officer)
and that the deponent is authorized to execute and file the
				  instrument. Deponent further says that deponent is familiar with the instrument
				  and the contents thereof, and that the facts therein set forth are true to the
				  best of deponent's knowledge, information, and belief.
(Signature) _______________________
(Type or print name beneath)
				  _______________________________