C.M.R. 02, 031, ch. 180, form 031-180-C
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 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 that permits proper evaluation by the Superintendent, and shall include specific references to Item numbers in the annual registration statement and to the terms contained therein.
Changes in the percentage of each class of voting securities held by each affiliate, reportable in Item 2 of Form B, need only be included where such changes 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 reportable in 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 a new president or chief executive officer of the ultimate controlling person is named.
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 pending or anticipated 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.
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 24-A M.R.S.A. § 222(8), the Registrant has caused this summary of changes to 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 summary of changes to 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-C