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

Current through July 13, 2024
INSURANCE HOLDING COMPANY SYSTEM ANNUAL
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:
________________________________________________________
________________________________________________________
________________________________________________________
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 method(s) 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 such control. As to each person specified in such 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:
(a) Name.
(b) Home office address.
(c) Principal executive office
				address.
(d) The organizational
				structure of the person, i.e., corporation, partnership, individual, trust,
				etc.
(e) The principal business of
				the person.
(f) The name and
				address of any person who holds or owns 10% or more of any class of voting
				security, the class of such security, the number of shares held of record or
				known to be beneficially owned, and the percentage of class so held or
				owned.
(g) 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
(a) 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,
				his or her 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, his or her principal occupation and all offices
				and positions held during the past five years, and any conviction of crimes
				other than minor traffic violations.
(b) Include a statement that the insurer's
				board of directors oversees corporate governance and internal controls and that
				the insurer's officers or senior management have approved, implemented, and
				continue to maintain and monitor corporate governance and internal control
				procedures.
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:
(a) loans, other investments, or purchases,
				sales or exchanges of securities of the affiliates by the Registrant or of the
				Registrant by its affiliates;
(b)
				purchases, sales or exchanges of assets;
(c) transactions not in the ordinary course
				of business;
(d) 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;
(e) all management
				agreements, service contracts and all cost-sharing arrangements;
(f) reinsurance agreements;
(g) dividends and other distributions to
				shareholders;
(h) consolidated tax
				allocation agreements; and
(i) any
				pledge of the Registrant's stock and/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 such information is not
				  material for purposes of Section
											26-44-104(e) of the
				  Act.
Sales, purchases, exchanges, loans or extensions of credit,
				  investments or guarantees involving one-half of 1% or less of the Registrant's
				  admitted assets as of December 31 of the immediately preceding year shall not
				  be deemed material.
The description shall be in a manner as to permit the proper
				  evaluation thereof by the Commissioner, and shall 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 such 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 such litigation or proceeding is or was pending:
(a) Criminal prosecutions or administrative
				proceedings by any government agency or authority which may be relevant to the
				trustworthiness of any party thereto; and
(b) 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, notification requirements and the review
				  that might otherwise occur.
ITEM 8. FINANCIAL STATEMENTS AND EXHIBITS
(a) 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.
(b) If the ultimate controlling person is a
				corporation, an organization, a limited liability company, or other legal
				entity, the financial statements shall 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 such
				  information is available. Such financial statements may be prepared on either
				  an individual basis, or unless the Commissioner otherwise requires, on a
				  consolidated basis if such consolidated statements are prepared in the usual
				  course of business.
Other than with respect to the foregoing, such financial
				  statement shall 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 GAAP 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 such 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 such 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.
(c) Exhibits shall 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 Regulation Sections 3 and 5.
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 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)
				  __________________________________________