Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 45 - Financial Standards and Corporate Operations › Part 1 - Insurance Holding Company Systems (230-RICR-20-45-1) › Section 230-RICR-20-45-1.25 - Form C: Summary Of Changes To Registration Statement

Current through June 14, 2024
Filed with the Insurance Department of the State of
								Rhode Island
By
______________________
Name of Registrant
On Behalf of Following Insurance Companies
Name Address
__________________________________________________________
Date: __________________ 20 __
Name, Title, Address and Telephone Number of
								Individual to Whom Notice 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 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 such changes are ones which
								result in ownership or holdings of 10 percent (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 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:
Pursuant to the requirements of R.I. Gen. Laws
								§
														27-35-3, 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
								_______________.
(SEAL)
____________________________Name of
								Registrant
By _________________________(Name) (Title)
Attest:
_______________________________(Signature of
								Officer)
_____________________________(Title)
CERTIFICATION
The undersigned deposes and says that he has duly
								executed the attached summary of registration statement dated
								__________________, for and on behalf of _____________________________ that he
								is the __________________________ of
__________________________________________________________
(Name of Company) (Title of Officer)
such company, and that he is authorized to execute
								and file such instrument. Deponent further says that he is familiar with such
								instrument and the contents thereof, and that the facts therein set forth are
								true to the best of his knowledge, information and belief.
(Signature)
								______________________________________________
(Type or print name beneath)
								_______________________