New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 2 - INSURANCE COMPANY LICENSING AND OPERATION › Part 2 - INSURANCE HOLDING COMPANIES › Section 13.2.2.14 - FORM C

Current through Register Vol. 35, No. 13, July 16, 2024
A.
When
				required:
An insurer required by Section
				59A-37-11
				NMSA 1978 to file an annual registration statement shall file Form C in
				accordance with the requirements of this rule.
B.
Where filed:
An insurer shall
				file a copy of Form C in each state in which the insurer is authorized to do
				business, if requested by the commissioner of that state.
C.
Information to be furnished in Form
				C:
(1)
Caption:
Place the
				following caption at the top of the cover page:
FORM C
SUMMARY OF CHANGES TO REGISTRATION STATEMENT FILED WITH THE
				  NEW MEXICO OFFICE OF SUPERINTENDENT OF INSURANCE
(2)
Registrant:
State the name
				of the registrant filing the statement.
(3)
Other registrants:
State the
				name and address of each insurance company on whose behalf the statement is
				being filed.
(4)
Date:
Provide the filing date of the statement.
(5)
Designation of agent:
State
				the name, title, address and telephone number of the individual to whom notices
				and correspondence concerning this statement should be addressed.
(6)
Changes:
Furnish a brief
				description of all items in the current annual registration statement that
				represent changes from the prior year's annual registration statement in such a
				manner as to permit the proper evaluation of the changes by the superintendent.
				Include specific references to item numbers and captions in the annual
				registration statement and to the terms contained in them.
(a)
Changes in Paragraph (7) of
				Subsection G of
				13.2.2.13
				NMAC
. Changes in the percentage of each class of voting securities held
				by each affiliate need only be included where such changes 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.
(b)
Changes in Paragraph (9) of
				Subsection G of
				13.2.2.13
				NMAC
. Include this information only if an individual is, for the first
				time, made a director or executive officer of the ultimate controlling person;
				an individual is named president of the ultimate controlling person; or a
				director or executive officer terminates his or her responsibilities with the
				ultimate controlling person.
(c)
Changes in Paragraph (10) of Subsection G of
				13.2.2.13
				NMAC
. If a transaction disclosed on the prior year's annual registration
				statement has been changed, describe the nature of such change. 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.
(7)
Signature and certification:
The following signature and certification are required at the end of Form C:
Pursuant to the requirements of Section
				  59A-37-12
				  NMSA 1978 has caused this annual registration statement to be duly signed on
				  its behalf in the city of and state of New Mexico on.
(SEAL)
____________________________
(Name of applicant)
BY:_________________________
Attest:
____________________________
(Signature of officer)
____________________________
(Title)
The undersigned deposes and says that they have duly executed
				  the attached annual registration statement dated, for and on behalf of ; that
				  they are the of such company; and that they are authorized to execute and file
				  this instrument. Deponent further says that they are familiar with the
				  instrument and its contents, and that the facts set forth in the instrument are
				  true to the best of their knowledge, information and belief.
____________________________
(Signature of deponent)
____________________________
(Typed name and title of deponent)