Neb. Admin. Code INSURANCE, DEPARTMENT OF, tit. 210, ch. 24, form C
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 a brief description of all items in the current annual registration statement which represents 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 Director, 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 is to avoid statutory threshold amounts and the review that might otherwise occur.
SIGNATURE AND CERTIFICATION
Pursuant to the requirements of § 44-2132(3) and 210 Neb. Admin. R. & Regs. 24, the Registrant has caused this summary of 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 summary of 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 is authorized to execute and file such instrument. Deponent further says that (s)he is familiar with such instrument and that the contents thereof, and that the facts therein set forth are true to the best of his/her knowledge, information and belief.
Neb. Admin. Code INSURANCE, DEPARTMENT OF, tit. 210, ch. 24, form C