23 CAR pt. 9, Appendix F. Enterprise Risk Report

FORM F ENTERPRISE RISK REPORT Filed with the Insurance Department of the State of______________________ By ____________________________________ Name of Registrant/Applicant On Behalf of/Related to Following Insurance Companies Name Address ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Date:_______________, 20_____ Name, Title, Address and telephone number of Individual to Whom Notices and Correspondence Concerning This Statement Should Be Addressed: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ITEM 1. ENTERPRISE RISK 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 Ark. Code Ann. § 23-63-503(9), provided such information is not disclosed in the Insurance Holding Company System Annual Registration Statement filed on behalf of itself or another insurer for which it is the ultimate controlling person: (a) Any material developments regarding strategy, internal audit findings, compliance or risk management affecting the insurance holding company system; (b) Acquisition or disposal of insurance entities and reallocating of existing financial or insurance entities within the insurance holding company system; (c) Any changes of shareholders of the insurance holding company system exceeding ten percent (10%) or more of voting securities; (d) Developments in various investigations, regulatory activities or litigation that may have a significant bearing or impact on the insurance holding company system; (e) Business plan of the insurance holding company system and summarized strategies for next twelve (12) months; (f) Identification of material concerns of the insurance holding company system raised by supervisory college, if any, in last year; (g) Identification of insurance holding company system capital resources and material distribution patterns; (h) 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 assessment of the insurance holding company system (including both the rating score and outlook); (i) Information on corporate or parental guarantees throughout the holding company and the expected source of liquidity should such guarantees be called upon; and (j) Identification of any 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 attach the appropriate form most recently filed with the U.S. Securities and Exchange Commission, provided the Registrant/Applicant includes specific references to those areas listed in Item 1 for which the form provides responsive information. If the Registrant/Applicant is not domiciled in the U.S., it may attach its most recent public audited financial statement filed in its country of domicile, provided the Registrant/Applicant includes specific references to those areas listed in Item 1 for which the financial statement provides responsive information. ITEM 2: OBLIGATION TO REPORT 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. CERTIFICATION The undersigned deposes and says that (s)he has duly executed the attached pre-acquisition notification dated _______________, (Year) _______, for and on behalf of ____________________ (Name of Applicant); 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 above)__________________________________