054.00.15 FORM B. Insurance Holding Company System Registration Statement
AR ADC 054.00.15 FORM BArkansas Administrative CodeEffective: January 1, 2016
Effective: January 1, 2016
Ark. Admin. Code 054.00.15 FORM B
054.00.15 FORM B. Insurance Holding Company System Registration Statement
Filed with the Insurance Department of the State of ______________________________
By
________________________________________
Name of Registrant
On Behalf of Following Insurance Companies
Name | Address |
__________________________________________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Date: ________________________________________, (Year) ____________________
Name, Title, Address and telephone number of Individuals to whom Notices and Correspondence Concerning This Statement Should be Addressed:
________________________________________________________________________________
____________________________________________________________
____________________________________________________________
Furnish the exact name of each insurer registering or being registered (hereinafter called “the Registrant”), the home office address and principal executive offices of each; the date on which each Registrant became part of the insurance holding company system; and the method(s) by which control of each Registrant was acquired and is maintained.
Furnish a chart or listing clearly presenting the identities of and interrelationships among all affiliated persons within the insurance holding company system. No affiliate need be shown if its total assets are equal to less than 1/2 of 1% (one percent) of the total assets of the ultimate controlling person within the insurance holding company system. The chart or listing should show the percentage of each class of voting securities of each affiliate which is owned, directly or indirectly, by another affiliate. If control of any person within the system is maintained other than by the ownership or control of voting securities, indicate the basis of such control. As to each person specified in such chart or listing indicate the type of organization (e.g., - corporation, trust, partnership) and the state or other jurisdiction of domicile.
As to the ultimate controlling person in the insurance holding company system, furnish the following information:
If the ultimate controlling person is a corporation, an organization, a limited liability company, or other legal entity, furnish the following information for the directors and executive officers of the ultimate controlling person: the individual's name and address, his or her principal occupation and all offices and positions held during the past five (5) years, and any conviction of crimes other than minor traffic violations. If the ultimate controlling person is an individual, furnish the individual's name and address, his or her principal occupation and all offices and positions held during the past five (5) years, and any conviction of crimes other than minor traffic violations.
Briefly describe the following agreements in force, and transactions currently outstanding or which have occurred during the last calendar year between the Registrant and its affiliates:
No information need be disclosed if such information is not material for purposes of Ark. Code Ann. § 23-63-514(c).
Sales, purchases, exchanges, loans or extensions of credit, investments or guarantees involving one-half of one percent (0.5%) or less of the Registrant's admitted assets as of the 31st day of December next preceding shall not be deemed material.
The description shall be in a manner as to permit the proper evaluation thereof by the Commissioner, and shall include at least the following: the nature and purpose of the transaction, the nature and amounts of any payments or transfers of assets between the parties, the identity of all parties to such transaction, and relationship of the affiliated parties to the Registrant.
A brief description of any litigation or administrative proceedings of the following types, either then pending or concluded within the preceding fiscal year, to which the ultimate controlling person or any of its directors or executive officers was a party or of which the property of any such person is or was the subject; give the names of the parties and the court or agency in which the litigation or proceeding is or was pending:
The insurer shall furnish a statement that transactions entered into since the filing of the prior registration statement are not part of a plan or series of like transactions, the purpose of which is to avoid statutory threshold amounts and the review that might otherwise occur.
If at the time of the initial registration, the annual financial statements for the latest fiscal year are not available, annual statements for the previous fiscal year may be filed and similar financial information shall be filed for any subsequent period to the extent such information is available. Such financial statements may be prepared on either an individual basis, or unless the Commissioner otherwise requires, on a consolidated basis if such consolidated statements are prepared in the usual course of business.
Unless the Commissioner otherwise permits, the annual financial statements shall be accompanied by the certificate of an independent public accountant to the effect that the statements present fairly the financial position of the ultimate controlling person and the results of its operations for the year then ended, in conformity with generally accepted accounting principles or with requirements of insurance or other accounting principles prescribed or permitted under law. If the ultimate controlling person is an insurer which is actively engaged in the business of insurance, the annual financial statements need not be certified, provided they are based on the Annual Statement of such insurer filed with the insurance department of the insurer's domiciliary state and are in accordance with requirements of the insurance or other accounting principles prescribed or permitted under the law and regulations of that state.
A Form C, Summary of Registration Statement, must be prepared and filed with this Form B.
Signature and certification required as follows:
SIGNATURE
Pursuant to the requirements of Ark. Code Ann. § 23-63-514, ____________________ the Registrant has caused this registration statement to be duly signed on its behalf in the City of _______________ and State of ____________________ on the __________ day of _______________, (Year) _______________.
________________________________________
Name of Registrant
(SEAL)
BY ________________________________________
(Name) (Title)
Attest:
________________________________________ | ______________________________ |
(Signature of Officer) | (Title) |
CERTIFICATION
The undersigned deposes and says that (s)he has duly executed the attached registration statement dated ____________________, (Year) __________, for and on behalf of (Name of Registrant) ____________________; 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 beneath) ________________________________________
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 B, AR ADC 054.00.15 FORM B
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