FORM B: CHANGES IN OWNERSHIP

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF EQUITY SECURITIES (Filed 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 2715.6404, Subpart 4): Statement for Calendar Month of _ , 197_. CHANGES DURING MONTH, AND MONTH-END OWNERSHIP (See Part 2715.6404, Subpart 5) Title of Security (See Part 2715.6404, Subpart 6) Date of Transaction (See Part 2715.6404, Subpart 7) Amount Bought or Otherwise Acquired Amount Sold or Otherwise Disposed of Amount Owned at End of Month Nature of Ownership (See Part 2715.6404, Subpart 9) (See Part 2715.6404, Subpart 8) . . . . . . . Remarks (See Part 2715.6404, Subparts 10 and 11): Date of Statement: Where Made: I affirm under penalty of perjury that the foregoing is full, true, and correct. _ (Signature)