C.M.R. 02, 031, ch. 180, form 031-180-B
Filed with the Bureau of Insurance of the State of Maine
BY
____________________________________
Name of Registrant
On Behalf of the Following Insurance Companies:
Name/Address _____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Dated: ____________________, 20___
Name, Title, Address, and Telephone Number of Individual to Whom Notices and Correspondence Concerning This Statement Should Be Addressed:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Furnish the exact name of each insurer registering or being registered (hereinafter called "the Registrant"); the home office address and principal executive offices of each; the date on which each Registrant became part of the insurance holding company system; and the method(s) by which control of each Registrant was acquired and is maintained.
Furnish a chart or listing clearly presenting the identities of and interrelationships among all affiliated persons within the insurance holding company system. The chart or listing should show the percentage of each class of voting securities of each affiliate which is owned, directly or indirectly, by another affiliate. If control of any person within the system is maintained other than by the ownership or control of voting securities, indicate the basis of such control. As to each person specified in such chart or listing indicate the type of organization (e.g., corporation, trust, partnership) and the state or other jurisdiction of domicile.
As to the ultimate controlling person in the insurance holding company system, furnish the following information:
If the ultimate controlling person is a corporation, an organization, a limited liability company, or other legal entity, furnish the following information for the directors and executive officers of the ultimate controlling person: the individual's name and address, his or her principal occupation and all offices and positions held during the past five years, and any conviction of crimes other than minor traffic violations. If the ultimate controlling person is an individual, furnish the individual's name and address, his or her principal occupation and all offices and positions held during the past five years, and any conviction of crimes other than minor traffic violations.
Briefly describe the following agreements in force, and transactions currently outstanding or which have occurred during the last calendar year between the Registrant and its affiliates:
No information need be disclosed if it is not considered material for purposes of 24-A M.R.S.A. § 222(8)(C).
Sales, purchases, exchanges, loans or extensions of credit, investments, or guarantees involving one-half of one percent or less of the Registrant's admitted assets as of the 31st day of December immediately preceding are not considered material, unless the Superintendent by order provides otherwise or they are part of a plan or series of like transactions that is material when evaluated in the aggregate.
The description shall be provided in a manner that permits proper evaluation by the Superintendent, and shall include at least the following: the nature and purpose of the transaction, the nature and amounts of any payments or transfers of assets between the parties, the identity of all parties to the transaction, and the relationship of the affiliated parties to the Registrant.
Furnish a brief description of any litigation or administrative proceedings of the following types, either then pending or concluded within the preceding fiscal year, to which the ultimate controlling person or any of its directors or executive officers was a party or of which the property of any such person is or was the subject; give the names of the parties and the court or agency in which any such litigation or proceeding is or was pending:
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, the purpose of which is to avoid statutory threshold amounts and the review that might otherwise occur.
If at the time of the initial registration, the annual financial statements for the latest fiscal year are not available, annual statements for the previous fiscal year may be filed and similar financial information shall be filed for any subsequent period to the extent such information is available. Such financial statements may be prepared on either an individual basis, or unless the Superintendent otherwise requires, on a consolidated basis if consolidated statements are prepared in the usual course of business.
Furnish documentation and financial statements filed with the Securities and Exchange Commission for entities that make such filings. To the extent that such documents and statements are unavailable or do not provide current and complete information for the holding company system, furnish audited GAAP financial statements or statements in a standard form and format adopted by the National Association of Insurance Commissioners, unless an alternative form is accepted by the Superintendent.
Unless the Superintendent otherwise permits, the annual financial statements shall be accompanied by the certificate of an independent public accountant to the effect that the statements present fairly the financial position of the ultimate controlling person and the results of its operations for the year then ended, in conformity with generally accepted accounting principles or with requirements of insurance or other accounting principles prescribed or permitted under law. If the ultimate controlling person is an insurer which is actively engaged in the business of insurance, the annual financial statements need not be certified, provided that they are based on the Annual Statement of that insurer filed with the insurance department of the insurer's domiciliary state and are in accordance with requirements of insurance or other accounting principles prescribed or permitted under the law and regulations of that state.
Any ultimate controlling person who is an individual may file personal financial statements that are reviewed rather than audited by an independent public accountant. The review shall be conducted in accordance with standards for review of personal financial statements published in the Personal Financial Statements Guide by the American Institute of Certified Public Accountants. Personal financial statements shall be accompanied by the independent public accountant's Standard Review Report stating that the accountant is not aware of any material modifications that should be made to the financial statements in order for the statements to be in conformity with generally accepted accounting principles.
Unless this is the initial Form B filing, a Form C, Summary of Changes to Registration Statement, must be prepared and filed with this Form B.
Signature and certification required as follows:
SIGNATURE:
Pursuant to the requirements of 24-A M.R.S.A. § 222(8), the 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 Company); that (s)he is the _________________________ (Title of Officer) of the Registrant; and that (s)he is authorized to execute and file this instrument.
Deponent further says that (s)he is familiar with this instrument and the contents hereof, and that the facts herein set forth are true to the best of his/her knowledge, information, and belief.
________________________________________________
Signature
________________________________________________
(Type or Print Name)
C.M.R. 02, 031, ch. 180, form 031-180-B