C.M.R. 02, 031, ch. 180, form 031-180-F
Filed with the Bureau of Insurance of the State of Maine
BY
____________________________________
Name of Registrant/Applicant
On Behalf/ Related to 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:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
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 24-A M.R.S.A. § 222(2) (B-2). If relevant information has been disclosed in the Insurance Holding Company System Annual Registration Statement (Form B) filed on behalf of itself or another insurer for which it is the ultimate controlling person, such information may simply be referenced here in lieu of making a duplicative filing:
* Any material developments regarding strategy, internal audit findings, compliance, or risk management affecting the insurance holding company system;
* Acquisition or disposal of insurance entities and reallocation of existing financial or insurance entities within the insurance holding company system;
* Any changes of shareholders of the insurance holding company system exceeding ten percent of voting securities;
* Developments in various investigations, regulatory activities, or litigation that may have a significant bearing or impact on the insurance holding company system;
* Business plan of the insurance holding company system and summarized strategies for the next 12 months;
* Identification of material concerns of the insurance holding company system raised by a supervisory college, if any, in the last year;
* Identification of insurance holding company system capital resources and material distribution patterns;
* 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 assessments of and within the insurance holding company system (including both the rating score and outlook);
* Information on corporate or parental guarantees throughout the holding company and the expected source of liquidity should such guarantees be called upon; and
* Identification of any other 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 respond to the extent relevant by attaching the appropriate form most recently filed with the United States Securities and Exchange Commission, or its most recent public audited financial statement filed in its country of domicile if that country is not the United States, provided that the Registrant/Applicant includes specific references to those areas listed in Item 1 for which the form provides responsive information.
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 1.
Signature and certification required as follows:
SIGNATURE:
Pursuant to the requirements of 24-A M.R.S.A. § 222 and Bureau of Insurance Rule 180, ___________________ has caused this application to be duly signed on its behalf in the City of ______________ and State of _________________ on the _______ day of ___________________, 20___.
(SEAL) _________________________________________
Name of Applicant
BY ____________________________________________
(Name) (Title)
ATTEST:
___________________________
(Signature of Officer)
________________________
(Title)
CERTIFICATION:
The undersigned deposes and says that (s)he has duly executed the attached application dated _______________, 20___, for and on behalf of ___________________ (Name of Applicant); that (s)he is the _____________________________ (Title of Officer) of the Applicant; 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-F