230 R.I. Code R. 230-RICR-20-45-1.25
Filed with the Insurance Department of the State of Rhode Island |
By |
______________________ |
Name of Registrant |
On Behalf of Following Insurance Companies |
Name Address |
__________________________________________________________ |
Date: __________________ 20 __ |
Name, Title, Address and Telephone Number of Individual to Whom Notice and Correspondence Concerning This Statement Should Be Addressed: |
________________________________________________________________ |
Furnish a brief description of all items in the current annual registration statement which represent 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 Commissioner, 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 (10%) 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 it is to avoid statutory threshold amounts and the review that might otherwise occur. |
SIGNATURE AND CERTIFICATION |
Signature and certification required as follows: |
Pursuant to the requirements of R.I. Gen. Laws § 27-35-3, 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 _______________. |
(SEAL) |
____________________________Name of Registrant |
By _________________________(Name) (Title) |
Attest: |
_______________________________(Signature of Officer) |
_____________________________(Title) |
CERTIFICATION |
The undersigned deposes and says that he has duly executed the attached summary of registration statement dated __________________, for and on behalf of _____________________________ that he is the __________________________ of |
__________________________________________________________ |
(Name of Company) (Title of Officer) |
such company, and that he is authorized to execute and file such instrument. Deponent further says that he is familiar with such instrument and the contents thereof, and that the facts therein set forth are true to the best of his knowledge, information and belief. |
(Signature) ______________________________________________ |
(Type or print name beneath) _______________________ |
230 R.I. Code R. 230-RICR-20-45-1.25