054.00.15 FORM E. Pre-Acquisition Notification Regarding the Potential Competitive Impact of a ...
AR ADC 054.00.15 FORM EArkansas Administrative CodeEffective: January 1, 2016
Effective: January 1, 2016
Ark. Admin. Code 054.00.15 FORM E
054.00.15 FORM E. Pre-Acquisition Notification Regarding the Potential Competitive Impact of a Proposed Merger or Acquisition by a Non-Domiciliary Insurer Doing Business in this State or by a Domestic Insurer
________________________________________
Name of Applicant
________________________________________
Name of Other Person Involved
In Merger or Acquisition
Filed with the Insurance Department of the State of ______________________________
Dated: ________________________________________, (Year) ____________________
Name, Title, Address and Telephone Number of Person Completing This Statement:
__________________________________________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
State the names and addresses of the persons who hereby provide notice of their involvement in a pending acquisition or change in corporate control.
State the names and addresses of the persons affiliated with those listed in Item 1. Describe their affiliations.
State the nature and purpose of the proposed merger or acquisition.
State the nature of the business performed by each of the persons identified in response to Item 1 and Item 2.
State specifically what market and market share in each relevant insurance market the persons identified in Item 1 and Item 2 currently enjoy in this state. Provide historical market and market share data for each person identified in Item 1 and Item 2 for the past five (5) years and identify the source of such data. Provide a determination as to whether the proposed acquisition or merger, if consummated, would violate the competitive standards of the state as stated in Ark. Code Ann. § 23-63-528. If the proposed acquisition or merger would violate competitive standards, provide justification of why the acquisition or merger would not substantially lessen competition or create a monopoly in the state.
For purposes of this notice “market” means direct written insurance premium in this state for a line of business as contained in the annual statement required to be filed by insurers licensed to do business in this state. Under Ark. Code Ann. § 23-63-525(1) “acquisition” is defined to include acquisition of assets, bulk reinsurance and mergers, as well as a change in control.
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) ________________________________________
Credits
Amended Jan. 1, 2016.
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 054.00.15 FORM E, AR ADC 054.00.15 FORM E
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