Neb. Admin. Code INSURANCE, DEPARTMENT OF, tit. 210, ch. 24, form B
Filed with the Insurance Department of the State of_________________________________
BY
__________________________________
Name of Registrant
On Behalf of the 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 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 systems; and the method(s) by which control of each Registrant was acquired and is maintained.
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.
As to the ultimate controlling person in the insurance holding company system furnish the following information:
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 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 principle occupation and all offices and positions held during the past five years, and any conviction of crimes other than minor traffic violations.
No information need be disclosed if such information is not material. Sales, purchases, exchanges, loans or extension of credit or investments involving 1/2 of 1% or less of the Registrant's admitted assets as of the 31st day of December next preceding shall not be deemed material.
The description shall be in a mariner as to penult the proper evaluation thereof by the Commissioner, and shall include at least the following: the nature and purpose of the transactions; 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.
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:
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 and the review that might otherwise occur.
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 Director.
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 Director 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 such insurer filed with the insurance department 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.
A Form C, Summary of Registration Statement, must be prepared and filed with this Form B.
Signatures and certification of the form as follows:
SIGNATURE
Pursuant to the requirements of § 44-2132 and 210 Neb. Admin. R. & Regs. 24, the Registrant has caused this 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 registration statement dated ______________, 20__________, for and on behalf of _______________, that (s)he is the____________ of such (Name of Company) (Title of Officer) company, and that (s)he has the authority to execute and file such instrument. Deponent further says that (s)he is familiar with such instrument and that the facts therein set forth are true to the best of his/her knowledge, information and belief.
(Type or print name beneath)___________________
Neb. Admin. Code INSURANCE, DEPARTMENT OF, tit. 210, ch. 24, form B