23 CAR pt. 2, Appendix A. Initial Statement of Beneficial Ownership of Securities

RULE AND REGULATION 3 FORM A INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 1 of Act 107 of 1965 ________________________________________________________________________________________________ (Name of Insurance Company) ________________________________________________________________________________________________ (Name of person whose ownership is reported) ________________________________________________________________________________________________ (Business address of such person: street, city, state, zip code) Relationship of such person to company named above. (See Instruction 9) ______________________________________ Date of event which requires the filing of this statement. (See Instruction 6) _____________________________________ SECURITIES BENEFICIALLY OWNED__________________________ TITLE Of SECURITY NATURE OF OWNERS AMOUNT OWNED (See Instruction 7) (See Instruction 8) beneficially (See Instruction 9) _______________________________________________________________________________________________ _______________________________________________________________________________________________ REMARKS: (See Instruction 10) I affirm under penalty of perjury that the foregoing is full, true, and correct. ___________________________ Signature ARKANSAS INSURANCE DEPARTMENT FORM A INSTRUCTIONS 1. PERSONS REQUIRED TO FILE STATEMENTS. A statement on this form is required to be filed by every person who is directly or indirectly the beneficial owner of more than 10 percent of any class of any equity security of an Arkansas stock insurance company, or who is a director or an officer of such a company. 2. WHEN STATEMENTS ARE TO BE FILED. (a) Persons who hold any of the relationships specified in instruction 1 are required to file a statement by 1 July, 1965, or within 10 days after assuming such relationship, whichever date is later. (b) Statements are not deemed to have been filed with the Commissioner until they have actually been received by him. 3. WHERE STATEMENTS ARE TO BE FILED. One signed copy of each statement shall be filed with the Commissioner of Insurance, (address). 4. SEPARATE STATEMENT FOR EACH COMPANY. A separate statement shall be filed with respect to the securities of each company. 5. RELATIONSHIP OF REPORTING PERSON TO COMPANY. Indicate clearly the relationship of the reporting person to the company; for example, "Director", "Director and Vice President", "Beneficial owner of more than 10 percent of the company's common stock", etc. 6. DATE AS OF WHICH BENEFICIAL OWNERSHIP IS TO BE GIVEN. The information as to beneficial ownership of securities shall be given as of 1 July, 1965, or, in the case of persons who subsequently assume any of the relationships specified in Instruction 1, as of the date that relationship was assumed. 7. TITLE OF SECURITY. The statement of the title of a security shall be such as clearly to identify the security even though there may be only one class; for example, "Class A Common Stock", "$6 Convertible Preferred Stock", "5% Debentures Due 1965", etc. 8. NATURE OF OWNERSHIP. Under "Nature of ownership", state whether ownership of the securities is "direct", or "indirect" If the ownership is indirect, i. e., through a partnership, corporation, trustor other entity, indicate, in a footnote or other appropriate manner, the name of identity of the medium through which the securities are indirectly owned. The fact that securities are held in the name of a broker or other nominee does not, of itself, constitute indirect partnership. Securities owned indirectly shall be reported on separate lines from those owned directly and also from those owned through a different type of indirect ownership. 9. STATEMENT OF AMOUNT OWNED. In stating the amount of securities beneficially owned, give the face amount of debt securities or the number of shares or other units of other securities. In the case of securities owned indirectly, the entire amount of securities owned by the partnership, corporation, trust or other entity shall be stated. The person whose ownership is reported may, if he so desires, also indicate in a footnote, or other appropriate manner, the extent of his interest in the partnership, corporation, trust or other entity. 10. INCLUSION OF ADDITIONAL INFORMATION. A statement may include any additional information or explanation deemed relevant by the person filing the statement. 11. SIGNATURE. If the statement is filed for a corporation, partnership, trust, etc., the same of the organization shall appear over the signature of the office or other person authorized to sign the statement. If the statement is filed for an individual, it shall be signed by him or specifically on his behalf by a person authorized to sign for him.