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 B - INSURANCE HOLDING COMPANY SYSTEM 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:
________________________________________________
________________________________________________
________________________________________________
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 methods by which control
				  of each registrant was acquired and is maintained.
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. 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 the 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.
ITEM 3. THE ULTIMATE CONTROLLING PERSON
As to the ultimate controlling person in the insurance
				  holding company system furnish the following information:
1. Name.
2. Home office address.
3. Principal executive office address.
4. The organizational structure of the person, i.e.,
				  corporation, partnership, individual, trust, etc.
5. The principal business of the person.
6. The name and address of any person who holds or owns ten
				  percent or more of any class of voting security, the class of the security, the
				  number of shares held of record or known to be beneficially owned, and the
				  percentage of class so held or owned.
7. 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.
ITEM 4. BIOGRAPHICAL INFORMATION
If the ultimate controlling person is a corporation, an
				  organization, a limited liability company, or other legal entity, furnish the
				  following information for the directors and executive officers of the ultimate
				  controlling person: the individual's name and address, the individual's
				  principal occupation and all offices and positions held during the past five
				  years, and any conviction of crimes other than minor traffic violations . If
				  the ultimate controlling person is an individual, furnish the individual's name
				  and address, principal occupation and all offices and positions held during the
				  past five years, and any conviction of crimes other than minor traffic
				  violations.
ITEM 5. TRANSACTIONS AND AGREEMENTS
Briefly describe the following agreements in force and
				  transactions currently outstanding or which have occurred during the last
				  calendar year between the registrant and its affiliates:
1. Loans, other investments, or purchases, sales, or
				  exchanges of securities of the affiliates by the registrant or of the
				  registrant by its affiliates;
2. Purchases, sales, or exchanges of assets;
3. Transactions not in the ordinary course of
				  business;
4. Guarantees or undertakings for the benefit of an
				  affiliate which result in an actual contingent exposure of the registrant's
				  assets to liability, other than insurance contracts entered into in the
				  ordinary course of the registrant's business;
5. All management agreements, service contracts, and all
				  cost-sharing arrangements;
6. Reinsurance agreements;
7. Dividends and other distributions to shareholders;
8. Consolidated tax allocation agreements; and
9. Any pledge of the registrant's stock or of the stock of
				  any subsidiary or controlling affiliate, for a loan made to any member of the
				  insurance holding company system.
No information need be disclosed if the information is not
				  material for purposes of North Dakota Century Code Section 26.1-10-04.
Sales, purchases, exchanges, loans, or extensions of credit,
				  investments, or guarantees involving one-half of one percent or less of the
				  registrant's admitted assets as of next preceding December thirty-first shall
				  not be deemed material.
The description must be in a manner as to permit the proper
				  evaluation thereof by the commissioner, and must include at least the
				  following: the nature and purpose of the transaction, the nature and amounts of
				  any payments or transfers of assets between the parties, the identity of all
				  parties to the transaction, and relationship of the affiliated parties to the
				  Registrant.
ITEM 6. LITIGATION OR ADMINISTRATIVE PROCEEDINGS
A brief description of any litigation or administrative
				  proceedings of the following types, either then pending or concluded within the
				  preceding fiscal year, to which the ultimate controlling person or any of its
				  directors or executive officers was a party or of which the property of any
				  such person is or was the subject; give the names of the parties and the court
				  or agency in which the litigation or proceeding is or was pending:
1. Criminal prosecutions or administrative proceedings by
				  any government agency or authority which may be relevant to the trustworthiness
				  of any party thereto; and
2. Proceedings which may have a material effect upon the
				  solvency or capital structure of the ultimate holding company including, but
				  not necessarily limited to, bankruptcy, receivership, or other corporate
				  reorganizations.
ITEM 7. STATEMENT REGARDING PLAN OR SERIES OF
				  TRANSACTIONS
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, the purpose of which is
				  to avoid statutory threshold amounts and the review that might otherwise
				  occur.
ITEM 8. FINANCIAL STATEMENTS AND EXHIBITS
1. Financial statements and exhibits should be attached to
				  this statement as an appendix, but list under this item the financial
				  statements and exhibits so attached.
2. If the ultimate controlling person is a corporation, an
				  organization, a limited liability company, or other legal entity, the financial
				  statements must include the annual financial statements of the ultimate
				  controlling person in the insurance holding company system as of the end of the
				  person's latest fiscal year.
If at the time of the initial registration, the annual
				  financial statements for the latest fiscal year are not available, annual
				  statements for the previous fiscal year may be filed and similar financial
				  information shall be filed for any subsequent period to the extent the
				  information is available. The financial statements may be prepared on either an
				  individual basis, or unless the commissioner otherwise requires, on a
				  consolidated basis if the consolidated statements are prepared in the usual
				  course of business.
Other than with respect to the foregoing, the financial
				  statement must be filed in a standard form and format adopted by the National
				  Association of Insurance Commissioners, unless an alternative form is accepted
				  by the commissioner. Documentation and financial statements filed with the
				  securities and exchange commission or audited generally accepted accounting
				  principles financial statements shall be deemed to be an appropriate form and
				  format.
Unless the commissioner otherwise permits, the annual
				  financial statements shall be accompanied by the certificate of an independent
				  public accountant to the effect that the statements present fairly the
				  financial position of the ultimate controlling person and the results of its
				  operations for the year then ended, in conformity with generally accepted
				  accounting principles or with requirements of insurance or other accounting
				  principles prescribed or permitted under law. If the ultimate controlling
				  person is an insurer which is actively engaged in the business of insurance,
				  the annual financial statements need not be certified, provided they are based
				  on the annual statement of the insurer's domiciliary state and are in
				  accordance with requirements of insurance or other accounting principles
				  prescribed or permitted under the law and regulations of the state.
Any ultimate controlling person who is an individual may
				  file personal financial statements that are reviewed rather than audited by an
				  independent public accountant. The review shall be conducted in accordance with
				  standards for review of personal financial statements published in the personal
				  financial statements guide by the American institute of certified public
				  accountants. Personal financial statements shall be accompanied by the
				  independent public accountant's standard review report stating that the
				  accountant is not aware of any material modifications that should be made to
				  the financial statements in order for the statements to be in conformity with
				  generally accepted accounting principles.
3. Exhibits must include copies of the latest annual reports
				  to shareholders of the ultimate controlling person and proxy material used by
				  the ultimate controlling person; and any additional documents or papers
				  required by Form B or North Dakota Administrative Code sections
				  45-03-05-04 and
				  45-03-05-06.
ITEM 9. FORM C REQUIRED
A Form C, Summary of Changes to Registration Statement, must
				  be prepared and filed with this Form B.
ITEM 10. 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 registrant)
By: ________________________________
(Name) (Title)
Attest:
_____________________________________
(Signature of officer)
____________________________________
(Title)
CERTIFICATION
The undersigned deposes and says that the undersigned has
				  duly executed the attached annual registration statement dated
				  ___________________ , 20 ___, for and on behalf of
				  _________________________________________ ; that the
(Name of company)
undersigned is the __________________________ of the company,
				  and that
(Title of officer)
the undersigned has authority to execute and file the
				  instrument. The deponent further says that deponent is familiar with the
				  instrument and the contents thereof, and that the facts herein set forth are
				  true to the best of deponent's knowledge, information, and belief.
(Signature) __________________________
(Type or print name beneath) _______________________