W. Va. Code R. agency 114, tit. 114, ser. 114-35, app C
FORM C
SUMMARY OF CHANGES TO REGISTRATION STATEMENT
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 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 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:
SIGNATURE
Pursuant to the requirements of W. Va. Code § 33-27-4, Registrant has caused this annual 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 annual registration statement 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 that (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)_____________________________
W. Va. Code R. agency 114, tit. 114, ser. 114-35, app C