23 CAR pt. 9, Appendix C. Summary of Registration Statement

FORM C SUMMARY OF 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: ________________________, (Year) ____________ Name, Title, Address and telephone number of Individuals to whom Notices and Correspondence Concerning This Statement Should be Addressed: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Furnish a brief description of all items in the current registration statement which represent changes from the prior registration statement. The description shall be in a manner so as to permit the proper evaluation thereof by the Commissioner, and shall include specific references to Item numbers in the 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 registration statement has been changed, the nature of such change shall be included. If a transaction disclosed on the prior 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 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 Ark. Code Ann. § 23-63-514, ______________ the Registrant has caused this summary of registration statement to be duly signed on its behalf in the City of _________________ and State of _______________ on the _______ day of ___________, (Year)__________. __________________________________ Name of Registrant (SEAL) BY________________________________ (Name) (Title) Attest: _______________________________ ________________________________ (Signature of Officer) (Title) CERTIFICATION The undersigned deposes and says that (s)he has duly executed the attached summary of registration statement dated _______________, (Year)_______, for and on behalf of ____________________ (Name of Registrant); 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) ________________________________