50 Ill. Adm. Code 204.EXHIBIT
B Statement of Changes in Beneficial Ownership of Securities
Section 204
Section 204.EXHIBIT B Statement
of Changes in Beneficial Ownership of Securities
STATE
OF ILLINOIS
Director
of Insurance
Form
2 – Statement of Changes in Beneficial Ownership of Securities
Filed
pursuant to Section 28.1 of the Illinois Insurance Code
(Name
of insurance company)
(Name
of person whose ownership is reported)
(Business
address of such person; street, city, zone, state)
Relationship of such person to
company named above. (See instruction 5)
Statement
for Calendar Month of ____________________, 19
_____
CHANGES
DURING MONTH AND MONTH-END OWNERSHIP (See instruction 6)
Title
of
Security
Date
of Transaction
Amount
Bought or Otherwise Acquired
Amount
sold or Otherwise Disposed of
Nature
of Ownership
Amount
Owned Beneficially at End of Month
(See Instruction 7)
(See Instruction 8)
(See Instruction 9)
(See Instruction 10)
(See Instruction 10)
(See Instruction 9)
REMARKS: (See instruction
11)
Subscribed and sworn to before
me this ____ day of ______________ A.D., 19___.
ILLINOIS
DEPARTMENTAL REGULATIONS
STATE
OF ILLINOIS
Director
of Insurance
Form 2– Instructions for Statement of Changes in Beneficial Ownership of
Securities
1. Persons Required to File Statements.
Statements on
this form are required to be filed by every person who at any time during any
calendar month was directly or indirectly the beneficial owner of more than 10
percent of any class of equity security of an Illinois stock insurance company,
or a director or officer of the company which is the issuer of such securities,
and who during such month had any change in his beneficial ownership of any
class of equity security of such company.
2. When Statements Are to Be Filed.
Statements are
required to be filed on or before the 10
th
day after the end of each
month in which any change in beneficial ownership has occurred. Statements are
not deemed to have been filed with the Director until they have actually been
received by him.
3. Where Statements Are to Be Filed.
4. One signed, sworn true copy of each statement shall be filed
with the Director of Insurance, State of Illinois, Springfield, Illinois 62767.
Separate
Statement For Each Company.
5. A
separate statement shall be filed with respect to the securities of each
company.
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. Transactions and Holdings to Be Reported.
Every
transaction shall be reported even though purchases and sales during the month
are equal or the change involves only the nature of ownership; for example,
from direct to indirect ownership. Beneficial ownership at the end of the
month of all classes of securities required to be reported shall be shown even
though there has been no change during the month in the ownership of securities
of one or more classes.
7. Title of Security.
The statement
of the title of the security shall be such as clearly to identify the security
even though there may be only one class; for example, "Class A Common
Stock", "5% Debentures Due 1965", etc.
8. Date of Transaction.
The exact date
(month, day and year) of each transaction shall be stated opposite the amount
involved in the transaction.
9. Statements of Amounts of Securities.
In stating the
amount of the securities acquired, disposed of, or 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, i.e., through a
partnership, corporation, trust or other entity, the entire amount of
securities involved in the transaction or 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 transaction or holdings
of the partnership, corporation, trust or other entity.
10. 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, trust or other entity, indicate in a
footnote, or other appropriate manner, the name or identity of the medium
through which the securities are indirectly owned. The fact that securities
are held in the name of the broker or other nominee does not, of itself,
constitute indirect ownership. Securities owned indirectly shall be reported
on separate lines from those owned directly and from those owned through a
different type of indirect ownership.
11. Character of Transaction.
If the
transaction was with the issuer of the securities, so state. If it involved the
purchase of securities through the exercise of options, so state and give the
exercise price per share. If any other purchase or sale was effected otherwise
than in the open market, that fact shall be indicated. If the transaction was
not a purchase or sale, indicated its character; for example, gift, 5% stock
dividend, etc. as the case may be. The foregoing information may be
appropriately set forth in the table or under "Remarks" at the end of
the table.
12. Inclusion of Additional Information.
A statement
may include any additional information or explanation deemed relevant by the
person filing the statement.
13. Signature.
If the
statement is filed for a corporation, partnership, trust, etc., the name of the
organization shall appear over the signature of the officer 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 is behalf by a person authorized
to sign for him.
In those cases
where the statement is signed by someone other than the person whose ownership
is being reported, documentary evidence of the signing authority shall be filed
with the statement.
In all cases
the signature must be duly notarized.