La. Admin. Code tit. 37 § XIII-7563

Current through Register Vol. 50, No. 11, November 20, 2024

Section XIII-7563 - Form B

A. Instructions

1. Persons Required to File Statements

a. Statements on this form are required to be filed by every person who at any time during any calendar month was directly or indirectly the beneficial owner of more than 10 percent of any class of equity security of a domestic stock insurance company, or a director or officer of the company which is the issuer of such securities, and who during such month had any change in his beneficial ownership of any class of equity security of such company.

2. When Statements Are to Be Filed

a. Statements are required to be filed on or before the tenth day after the end of each month in which any change in beneficial ownership has occurred. Statements are not deemed to have been filed with the commissioner until they have actually been received by him.

3. Where Statements Are to Be Filed

a. One signed copy of each statement shall be filed with the Commissioner of Insurance, P. 0. Box 44214, Baton Rouge, Louisiana.

4. Separate Statement for Each Company

a. A separate statement shall be filed with respect to the securities of each company.

5. Relationship of Reporting Person to Company

a. Indicate clearly the relationship of the reporting person to the company, for example, "Director", "Director and Vice President", "Beneficial owner of more than 10 percent of the company's common stock", etc.

6. Transactions and Holdings to Be Reported

a. Every transaction shall be reported even though purchases and sales during the month are equal or the change involves only the nature of ownership, for example, from direct to indirect ownership. Beneficial ownership at the end of the month of all classes of securities required to be reported shall be shown even though there has been no change during the month in the ownership of securities of one or more classes.

7. Title of Security

a. The statement of the title of the security shall be such as clearly to identify the security even though there may be only one class, for example, "Class A Common Stock", "Common Stock", etc.

8. Date of Transaction

a. The exact date (month, day and year) of each transaction shall be stated opposite the amount involved in the transaction.

9. Statement of Amounts of Securities

a. In stating the amount of the securities acquired, disposed of, or beneficially owned, give the face amount of debt securities or the number of shares or other units of other securities. In the case of securities owned indirectly (i.e., through a partnership, corporation, trust or other entity) the entire amount of securities involved in the transaction or owned by the partnership, corporation, trust or other entity shall be stated. The person whose ownership is reported may, if he so desires, also indicate in a footnote or other appropriate manner, the extent of his interest in the transaction or holdings of the partnership, corporation, trust or other entity.

10. Nature of Ownership

a. Under "Nature of Ownership", state whether ownership of the securities is "direct" or "indirect". If the ownership is indirect (i.e., through a partnership, corporation, trust or other entity) indicate in a footnote or other appropriate manner, the name or identity of the medium through which the securities are indirectly owned. The fact that securities are held in the name of a broker or other nominee does not, of itself, constitute indirect ownership. Securities owned indirectly shall be reported on separate lines from those owned directly and from those owned through a different type of indirect ownership.

11. Character of Transaction

a. If the transaction was with the issuer of the securities, so state. If it involved the purchase of securities through the exercise of options, so state and give the exercise price per share. If any other purchase or sale was effected otherwise than in the open market, that fact shall be indicated. If the transaction was not a purchase or sale, indicate its character (for example, gift, 5 percent stock dividend, etc.), as the case may be. The foregoing information may be appropriately set forth in the table or under "Remarks" at the end of the table.

12. Inclusion of Additional Information

a. A statement may include any additional information or explanation deemed relevant by the person filing the statement.

13. Signature

a. If the statement is filed for a corporation, partnership, trust, etc., the name of the organization shall appear over the signature of the officer or other person authorized to sign the statement. If the statement is filed for an individual, it shall be signed by him or specifically on his behalf by a person authorized to sign for him.

B. Form

STATE OF LOUISIANA

COMMISSIONER OF INSURANCE INSIDER TRADING

BATON ROUGE

DUDLEY A. GUGLIELMO

COMMISSIONER

FORM B

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES

Filed pursuant to Act Eight of 1966

_____________________________________________________________________________________________________________________________ (Name of insurance company) _____________________________________________________________________________________________________________________________ (Name of person whose ownership is required) _____________________________________________________________________________________________________________________________ (Business address of such person: street, city, zone, state) Relationship of such person to company named above. (See instruction 5) _________________________________________________________________ _____________________________________________________________________________________________________________________________

Statement for Calendar Month of ____________________, 20______

CHANGES DURING MONTH AND MONTH-END OWNERSHIP (See instruction 6.)

TITLE OF SECURITY (See instruction 7)

DATE OF TRANSACTION (See instruction 8)

AMOUNT BOUGHT or otherwise acquired (See instruction 9)

AMOUNT SOLD or otherwise disposed of (See instruction 9)

NATURE OF OWNERSHIP (See instruction 10)

AMOUNT OWNED beneficially at end of month (See instruction 9)

REMARKS: (See instructions 11 and 12) I affirm under penalty of perjury that the foregoing is full, true, and correct.

________________________________________________________________________________________________________________________

Date of Statement_________________________________

(Signature)_______________________________________

________________________________________________

La. Admin. Code tit. 37, § XIII-7563

Promulgated by the Department of Insurance, Commissioner of Insurance, July 1, 1966, amended April 1, 1967.

AUTHORITY NOTE: Promulgated in accordance with R.S. 22:2.