The purpose of this rule is to establish the form and content an insurer must use in order to give notice of a proposed transaction under section 3901.341 of the Revised Code.
This rule is promulgated pursuant to the authority vested in the superintendent under sections 3901.041 and 3901.341 of the Revised Code.
Terms found in this regulation are used as defined in the Insurance Holding Company Systems Regulatory Act, sections 3901.32 to 3901.37 of the Revised Code, and rule 3901-3-02 of the Administrative Code.
In giving notice to the superintendent of a proposed transaction pursuant to section 3901.341 of the Revised Code, the insurer shall use the form set forth in this paragraph.
Form D
Prior notice of a transaction
Filed with the insurance department of the state of Ohio
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:
______________________________
______________________________
______________________________
Item 1. Identity of parties to transaction
Furnish the following information for each of the parties to the transaction:
Item 2. Description of the transaction
Furnish the following information in electronic form prescribed by the superintendent for each transaction for which notice is being given:
Item 3. Sales, purchases, exchanges, loans, extensions of credit, guarantees or investments
If notice is being given under division (A)(1) of section 3901.341 of the Revised Code, furnish a brief description of the amount and source of funds, securities, property or other consideration for the sale, purchase, exchange of assets, loan, extension of credit, guarantee, or investment. If any securities are involved in the transaction, provide a description of the terms of the securities.
If consideration for the transaction is other than cash describe the consideration, its cost, and fair market value, and explain the basis for evaluation.
If the transaction involves a loan, extension of credit or a guarantee, furnish a description of the maximum amount which the insurer will be obligated to make available under such loan, extension of credit or guarantee, the date on which the credit or guarantee will terminate, and any provisions for the accrual of or deferral of interest.
If the transaction involves an investment, guarantee or other arrangement, state the time period during which the investment, guarantee or other arrangement will remain in effect, together with any provisions for extensions or renewals of such investments, guarantees or arrangements. Furnish a brief statement as to the effect of the transaction upon the insurer's surplus.
No notice need be given if the maximum amount which can at any time be outstanding or for which the insurer can be legally obligated under the loan, extension of credit or guarantee is less than, (a) in the case of non-life insurers, the lesser of three percent of the insurer's admitted assets or twenty-five percent of surplus as regards policyholders or, (b) in the case of life insurers, three percent of the insurer's admitted assets, each as of the thirty-first day of December next preceding.
Item 4. Loans or extensions of credit to a non-affiliate
If the transaction involves a loan or extension of credit to any person who is not an affiliate, furnish a brief description of the agreement or understanding whereby the proceeds of the proposed transaction, in whole or in substantial part, are to be used to make loans or extensions of credit to, to purchase the assets of, or to make investments in, any affiliate of the insurer making such loans or extensions of credit, and specify in what manner the proceeds are to be used to loan to, extend credit to, purchase assets of or make investments in any affiliate. Describe the amount and source of funds, securities, property or other consideration for the loan or extension of credit and, if the transaction is one involving consideration other than cash, a description of its cost and its fair market value together with an explanation of the basis for evaluation. Furnish a brief statement as to the effect of the transaction upon the insurer's surplus.
No notice need be given if the loan or extension of credit is one which equals less than, in the case of non-life insurers, the lesser of three percent of the insurer's admitted assets or twenty-five percent of surplus as regards policyholders or, with respect to life insurers, three percent of the insurer's admitted assets, each as of the thirty-first day of December next preceding.
Item 5. Reinsurance
If the transaction is a reinsurance agreement or modification thereto, as described by division (A)(3) of section 3901.341 of the Revised Code, furnish a description of the known and/or estimated amount of liability to be ceded and/or assumed in each calendar year, the period of time during which the agreement will be in effect, and a statement whether an agreement or understanding exists between the insurer and nonaffiliate to the effect that any portion of the assets constituting the consideration for the agreement will be transferred to one or more of the insurer's affiliates. Furnish a brief description of the consideration involved in the transaction, and a brief statement as to the effect of the transaction upon the insurer's surplus.
No notice need be given for reinsurance agreements or modifications thereto if the reinsurance premium or a change in the insurer's liabilities in connection with the reinsurance agreement or modification thereto is less than five percent of the insurer's surplus as regards policyholders, as of the thirty-first day of December next preceding.
Item 6. Management agreements, service agreements, cost-sharing arrangements and tax allocation agreements.
For management and service agreements, furnish:
For cost-sharing arrangements, furnish:
Item 7. Signature and certification
Signature and certifications required as follows:
Signature
Pursuant to the requirements of section 3901.341 of the Revised Code,___________ has caused this notice to be duly signed on its behalf in the city of _______________________________ and state of ________________________ on the _______ day of ________, 20____.
(Seal) _________________________________
Name of applicant
By ______________________________
(Name) (Title)
Attest:
(Signature of officer)
______________________________
(Title)
Certification
The undersigned deposes and says that (s)he has duly executed the attached notice dated _______, 20____, for and on behalf of __________________(Name of applicant); 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 the (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)__________________________
If any paragraph, term or provision of this rule is adjudged invalid for any reason, the judgement shall not affect, impair or invalidate any other paragraph, term or provision of this rule, but the remaining paragraphs, terms and provisions shall be and continue in full force and effect.
Ohio Admin. Code 3901-3-03
Five Year Review (FYR) Dates: 8/30/2025
Promulgated Under: 119.03
Statutory Authority: 3901.041, 3901.341
Rule Amplifies: 3901.341
Prior Effective Dates: 11/09/1991, 04/13/2006, 10/29/2015