760 IAC 1-15.1-6 Form C

Sec. 6. Form C, concerning summary of registration statement, shall be as follows: FORM C SUMMARY OF REGISTRATION STATEMENT Filed with the INDIANA INSURANCE COMMISSIONER By Name of Registrant On behalf of the 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: FORM C Item 1. Changes in Prior Statement (a) Furnish a brief description of all items in the current annual registration statement which represent changes from the prior year's annual registration statement. The description shall be in a manner as to permit the proper evaluation thereof by the commissioner and shall include specific references to Item numbers in the annual registration statement and to the terms contained therein. (b) Changes occurring under Item 2 of Form B insofar as changes in the percentage of each class of voting securities held by each affiliate are concerned, need only be included where such changes are ones which result in ownership or holdings of ten percent (10%) or more of voting securities, loss or transfer of control, or acquisition or loss of partnership interest. (c) 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 name president of the ultimate controlling person. (d) If a transaction disclosed on the prior year's annual registration statement has been changed, the nature of such change shall be included. If a transaction disclosed on the prior year's annual registration statement has been effectuated, furnish the mode of completion and any flow of funds between affiliates resulting from the transaction. Item 2. Statement Regarding Plan or Series of Transactions The registrant shall furnish a statement that transactions entered into since the filing of the prior year's annual 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. Item 3. Signature and Certification Signature and certification required as follows: SIGNATURE Pursuant to the requirements of IC 27-1-23-3 and Regulations promulgated by the Indiana Insurance Commissioner, (Name of Registrant) has caused this Statement to be duly signed on its behalf in the City of __________ and State of _________ on the _____ day of __________, 20 ___. (Name of Registrant) By Name Title Attest: (Signature of Officer) (Title) CERTIFICATION The undersigned deposes and says that he or she has duly executed the attached Statement dated ___________, 20 ___, for and on behalf of (Name of Registrant), and that he or she is authorized to execute and file such instrument. Deponent further says that he or she is familiar with such instrument and the contents thereof and that the facts therein set forth are true to the best of his or her knowledge, information, and belief. (Signature)_________________________________________ (Type or print name)_________________________________