Pa. Code tit. 31, pt. I, subpt. B, ch. 25, app A, form F
Filed with the Insurance Department of ________.
By
_______________
Name of Registrant/Applicant
On Behalf of/Related to 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. Enterprise Risk
The Registrant/Applicant, to the best of its knowledge and belief, shall provide information regarding the following areas that could produce enterprise risk as defined in section 1401 of the act (40 P. S. § 991.1401) provided such information is not disclosed in the Insurance Holding Company System Annual Registration Statement filed on behalf of itself or another insurer for which it is the ultimate controlling person:
A. Any material developments regarding strategy, internal audit findings, compliance or risk management affecting the insurance holding company system.
B. Acquisition or disposal of insurance entities and reallocating of existing financial or insurance entities within the insurance holding company system.
C. Any changes of shareholders of the insurance holding company system exceeding ten percent (10%) or more of voting securities.
D. Developments in various investigations, regulatory activities or litigation that may have a significant bearing or impact on the insurance holding company system.
E. Business plan of the insurance holding company system and summarized strategies for next 12 months.
F. Identification of material concerns of the insurance holding company system raised by a supervisory college, if any, in last year.
G. Identification of insurance holding company system capital resources and material distribution patterns.
H. Identification of any negative movement, or discussions with rating agencies which may have caused, or may cause, potential negative movement in the credit ratings and individual insurer financial strength ratings assessment of the insurance holding company system (including both the rating score and outlook).
I. Information on corporate or parental guarantees throughout the holding company and the expected source of liquidity should such guarantees be called upon.
J. Identification of any material activity or development of the insurance holding company system that, in the opinion of senior management, could adversely affect the insurance holding company system.
The Registrant/Applicant may attach the appropriate form most recently filed with the U.S. Securities and Exchange Commission, provided the Registrant/Applicant includes specific references to those areas listed in Item 1 for which the form provides responsive information. If the Registrant/Applicant is not domiciled in the U.S., it may attach its most recent public audited financial statement filed in its country of domicile, provided the Registrant/ Applicant includes specific references to those areas listed in Item 1 for which the financial statement provides responsive information.
Item 2: Obligation to Report
If the Registrant/Applicant has not disclosed any information pursuant to Item 1, the Registrant/Applicant shall include a statement affirming that, to the best of its knowledge and belief, it has not identified enterprise risk subject to disclosure pursuant to Item.
Item 3: Signature and Certification
SIGNATURE AND CERTIFICATION
Signature and certification required as follows:
Pa. Code tit. 31, pt. I, subpt. B, ch. 25, app A, form F