FORM A: STATEMENT OF OWNERSHIP

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF EQUITY SECURITIES (File with Respect to Domestic Stock Insurer Pursuant to Minnesota Statutes, Section 60A.22) Name of Insurer: Address: Name of Person Whose Ownership is Reported: Address: Relationship of Such Person to Insurer (See Part 2715.6402, Subpart 4): Date Indicated Relationship Occurred: EQUITY SECURITIES BENEFICIALLY OWNED Title of Security (See Part 2715.6402, Subpart 5) Nature of Ownership (See Part 2715.6402, Subpart 6) Amount Beneficially Owned (See Part 2715.6402, Subpart 7) . . . . . . . . Remarks (See Part 2715.6402, Subpart 8): I affirm under penalty of perjury that the foregoing is full, true, and correct. Date of Statement: Where Made: _ (Signature)