054.00.15 FORM F. Enterprise Risk Report
AR ADC 054.00.15 FORM FArkansas Administrative CodeEffective: January 1, 2016
Effective: January 1, 2016
Ark. Admin. Code 054.00.15 FORM F
054.00.15 FORM F. Enterprise Risk Report
Filed with the Insurance Department of the State of ______________________________
By
________________________________________
Name of Registrant/Applicant
On Behalf of/Related to 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:
____________________________________________________________
____________________________________________________________
____________________________________________________________
The Registrant/Applicant, to the best of its knowledge and belief, shall provide information regarding the following areas that could produce enterprise risk as defined in Ark. Code Ann. ยง 23-63-503(9), provided such information is not disclosed in the Insurance Holding Company System Annual Registration Statement filed on behalf of itself or another insurer for which it is the ultimate controlling person:
(h) Identification of any negative movement, or discussions with rating agencies which may have caused, or may cause, potential negative movement in the credit ratings and individual insurer financial strength ratings assessment of the insurance holding company system (including both the rating score and outlook);
The Registrant/Applicant may attach the appropriate form most recently filed with the U.S. Securities and Exchange Commission, provided the Registrant/Applicant includes specific references to those areas listed in Item 1 for which the form provides responsive information. If the Registrant/Applicant is not domiciled in the U.S., it may attach its most recent public audited financial statement filed in its country of domicile, provided the Registrant/Applicant includes specific references to those areas listed in Item 1 for which the financial statement provides responsive information.
If the Registrant/Applicant has not disclosed any information pursuant to Item 1, the Registrant/Applicant shall include a statement affirming that, to the best of its knowledge and belief, it has not identified enterprise risk subject to disclosure pursuant to Item 1.
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
Adopted 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 F, AR ADC 054.00.15 FORM F
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