Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-18 - Washington insurance holding company regulation › Section 284-18-930 - Form C

Current through Register Vol. 24-14, July 15, 2024
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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 must be in a manner as to permit the
				proper evaluation thereof by the commissioner, and must 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 annual
				registration statement has been changed, the nature of the change must 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 must 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
Under the requirements of
				RCW
				 48.31B.025, 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 (Name of Company ; that (s)he is the (Title of Officer) of the
				company and that (s)he is authorized to execute and file the instrument.
				Deponent further says that (s)he is familiar with such instrument and the
				contents thereof, and that the facts therein set forth are true to the best of
				his/her knowledge, information and belief.
(Signature)______________
(Type or print name beneath)______________
Statutory Authority:
				  RCW
				   48.02.060 and 1993 c 462 § 9. 93-19-005
				  (Order R 93-9), §
										284-18-930, filed 9/1/93,
				  effective 10/2/93.