Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 40 - Insurance Holding Company System Regulation › Subchapter II - Insurance Holding Company Systems-Reporting Forms › Appendix - Appendix › Form C - SUMMARY OF CHANGES TO REGISTRATION STATEMENT

Current through June 24, 2024
Filed with the office of the commissioner of
					 insurance,
state of Wisconsin
By
Name of Registrant
On behalf of following insurers
Name: Address:
Date:_ _ ,_ _
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 annual
					 registration statement, form B, which are required to be filed with this form,
					 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 described where such changes are ones which result in
					 ownership or holdings of 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
					 described 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 immediately 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, describe 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 immediately prior year's annual
					 registration statement are not part of a group or series of like transactions
					 or entered into for the purpose of avoiding reporting threshold amounts.
SIGNATURE
Signature and certification required as follows:
Pursuant to the requirements of ch. Ins 40, Wis. Adm. Code,
					 Registrant has caused this annual summary of the registration statement to be
					 duly signed on its behalf of the city of_ _ _ and State of_ _ _ on the_ _ day
					 of_ _ , .
(SEAL)_ _ _
Name of Registrant
BY_ _ _
(Name) (Title)
Attest:
_ _ _
(Signature of Officer)
_ _ _
(Title)
The undersigned deposes and says that (s)he has duly
					 executed the attached annual registration statement dated, , for and on behalf
					 of; that (s)he is the (Title of Officer) of such Registrant 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)
Subscribed and sworn to this
day of ,
Notary Public
My commission expires