Wyoming Administrative Code › Agency 044 - Insurance Dept › Sub-Agency 0002 - General Agency, Board or Commission Rules › Chapter 45 - HOLDING COMPANY SYSTEM › Form C

Current through July 13, 2024
SUMMARY OF CHANGES TO REGISTRATION STATEMENT
Filed with the Insurance Department
of the State of ______________________
BY
_________________________________________________
Name of Registrant
On Behalf of 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
				  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 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, notification requirements and the review
				  that might otherwise occur.
SIGNATURE AND CERTIFICATION
Signature and certification required as follows:
SIGNATURE
Pursuant to the requirements of Section
										26-44-104 of the Act, 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 (s)he has duly executed
				  the attached annual registration statement dated _________________________ , 20
				  _____ , for and on behalf of
_____________________________________________________________________________
				  ;
(Name of Company)
that (s)he is the
				  _________________________________________________________________
(Title of Officer) of such company and that (s)he is
				  authorized to execute and file such 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)____________________________