Notes
Ala. Admin. Code
r. 482-1-055-.21
Revised: July 5, 1994;
effective July 15, 1994. Filed for codification in the Alabama Administrative
Code by the Department of Insurance on June 10, 2003, pursuant to the Code of
Ala. 1975, § 27-7-43. FORM A STATEMENT REGARDING THE ACQUISITION OF
CONTROL OF OR MERGER WITH A DOMESTIC INSURER
_____________________________________ Name of Domestic Insurer BY
_____________________________________ Name of Acquiring Person (Applicant)
Filed with the ALABAMA DEPARTMENT OF INSURANCE. Dated:
_________________________, 19 _______ Name, Title, address and telephone number
of individual to whom Notices and Correspondence concerning this Statement
should be addressed:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________ ITEM 1.
INSURER AND METHOD OF ACQUISITION State the name and address of the domestic
insurer to which this application relates and a brief description of how
control is to be acquired. ITEM 2. IDENTITY AND BACKGROUND OF THE APPLICANT (a)
State the name and address of the applicant seeking to acquire control over the
insurer. (b) If the applicant is not an individual, state the nature of its
business operations for the past 5 years or for such lesser period as such
person and any predecessors thereof shall have been in existence. Briefly
describe the business intended to be done by the applicant and the applicant's
subsidiaries. (c) Furnish a chart or listing clearly presenting the identities
of the interrelationships among the applicant and all its total assets are
equal to less than 1/2 of 1% of the total assets of the ultimate controlling
person affiliated with the applicant. Indicate in such chart or listing the
percentage of voting securities of each such person which is owned or
controlled by the applicant or by any other such person. If control of any
person 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. If court
proceedings involve a reorganization or liquidation are pending with respect to
any such person, indicate which person, and set forth the title of the court,
nature of proceedings and the date when commenced. ITEM 3. IDENTITY AND
BACKGROUND OF INDIVIDUALS ASSOCIATED WITH THE APPLICANT State the following
with respect to (1) the applicant if (s)he is an individual or (2) all persons
who are directors, executive officers or owners of 5% or more of the voting
securities of the applicant if the applicant is not an individual. (a) Name and
business address; (b) Present principal business activity, occupation or
employment including position and office held and the name, principal business
and address of any corporation or other organization in which such employment
is carried on; (c) Material occupations, positions, offices or employment
during the last 5 years, giving the starting and ending dates of each and the
name, principal business and address of any business corporation or other
organization in which each such occupation, position, office or employment was
carried on; if licensing by or registration with any federal, state or
municipal governmental agency, indicate such fact, the current status of such
licensing or registration, and an explanation of any surrender, revocation,
suspension or disciplinary proceedings in connection therewith. (d) Whether or
not such person has ever been convicted in a criminal proceeding (excluding
minor traffic violations) during the last 10 years and, if so, give the date,
nature of conviction, name and location of court, and penalty imposed or other
disposition of the case. ITEM 4. NATURE, SOURCE AND AMOUNT OF CONSIDERATION (a)
Describe the nature, source and amount of funds or other considerations used or
to be used in effecting the merger or other acquisition of control. If any part
of the same is represented or is to be represented by funds or other
consideration borrowed or otherwise obtained for the purpose of acquiring,
holding or trading securities, furnish a description of the transaction, the
names of the parties thereto, the relationship, if any, between the borrower
and the lender, the amounts borrowed or to be borrowed, and copies of all
agreements, promissory notes and security arrangements relating thereto. (b)
Explain the criteria used in determining the nature and amount of such
consideration. (c) If the source of the consideration is a loan made in the
lender's ordinary course of business and if the applicant wishes the identity
of the lender to remain confidential, he must specifically request that the
identity be kept confidential. ITEM 5. FUTURE PLANS OF INSURER Describe any
plans or proposals which the applicant may have to declare an extraordinary
dividend, to liquidate the insurer, to sell its assets to or merge it with any
person or persons or to make any other material change in its business
operations or corporate structure or management. ITEM 6. VOTING SECURITIES TO
BE ACQUIRED State the number of shares of the insurer's voting securities which
the applicant, its affiliates and any person listed in Item 3 plan to acquire,
and the terms of the offer, request, invitation, agreement or acquisition, and
a statement as to the method by which the fairness of the proposal was arrived
at. ITEM 7. OWNERSHIP OF VOTING SECURITIES State the amount of each class of
any voting security of the insurer which is beneficially owned or concerning
which there is a right to acquire beneficial ownership by the applicant, its
affiliates or any person listed in Item 3. ITEM 8. CONTRACTS, ARRANGEMENTS, OR
UNDERSTANDINGS WITH RESPECT TO VOTING SECURITIES OF THE INSURER Give a full
description of any contracts, arrangements or understandings with respect to
any voting security of the insurer in which the applicant, its affiliates or
any person listed in Item 3 is involved, including but not limited to transfer
of any of the securities, joint ventures, loan or option arrangements, puts or
calls, guarantees of loans, guarantees against loss of guarantees of profits,
division of losses or profits, or the giving or withholding of proxies. Such
description shall identify the persons with whom the contracts, arrangements or
understandings have been entered into. ITEM 9. RECENT PURCHASES OF VOTING
SECURITIES Describe any purchases of any voting securities of the insurer by
the applicant, its affiliates or any person listed in Item 3 during the 12
calendar months preceding the filing of this statement. Include in the
description the dates of purchase, the names of the purchasers, and the
consideration paid or agreed to be paid therefor. State whether any shares so
purchased are hypothecated. ITEM 10. RECENT RECOMMENDATIONS TO PURCHASE
Describe any recommendations to purchase any voting security of the insurer
made by the applicant, its affiliates or any person listed in Item 3, or by
anyone based upon interviews or at the suggestion of the applicant, its
affiliates or any person listed in Item 3 during the 12 calendar months
preceding the filing of this statement. ITEM 11. AGREEMENTS WITH BROKER-DEALERS
Describe the terms of any agreement, contract or understanding made with any
broker-dealer as to solicitation of voting securities of the insurer for tender
and the amount of any fees, commissions or other compensation to be paid to
broker-dealers with regard thereto. ITEM 12. FINANCIAL STATEMENTS AND EXHIBITS
(a) Financial statements and exhibits shall be attached to this statement as an
appendix, but list under this item the financial statements and exhibits so
attached. (b) The financial statements shall include the annual financial
statements of the persons identified in Item 2(c) for the preceding 5 fiscal
years (or for such lesser period as such applicant and its affiliates and any
predecessors thereof shall have been in existence), and similar information
covering the period from the end of such person's last fiscal year, if the
information is available. The statements may be prepared on either an
individual basis, or, unless the Commissioner other requires, on a consolidated
basis if consolidated statements are prepared in the usual course of business.
The annual financial statements of the applicant shall be accompanied by the
certificate of an independent public accountant to the effect that such
statements present fairly the financial position of the applicant 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 applicant is an
insurer which is actively engaged in the business of insurance, the financial
statements need not be certified, provided they are based on the Annual
Statement of the person filed with the Insurance Department of the person's
domiciliary state and are in accordance with the requirements of insurance or
other accounting principles prescribed or permitted under the law and
regulations of the state. (c) File as exhibits copies of all tender offers for,
requests or invitations for, tenders of, exchange offers for, and agreements to
acquire or exchange any voting securities of the insurer and (if distributed)
of additional soliciting material relating thereto, any proposed employment,
consultation, advisory or management contracts concerning the insurer, annual
reports to the stockholders of the insurer and the applicant for the last two
fiscal years, and any additional documents or papers required by Form A or
regulation Section 4 and 6. ITEM 13. SIGNATURE AND CERTIFICATION Signature and
certification required as follows: SIGNATURE Pursuant to the requirements of
Section 27-29-3, Code of Alabama 1975, _____________________________________
has caused this application to be duly signed on its behalf in the City of
__________________ and State of ________________ on the _________ day of
_______________________, 19 ____. (Seal) ___________________________________
Name of Applicant BY ___________________________________ (Name) (Title) Attest:
__________________________________________ (Signature of Officer)
__________________________________________ (Title) CERTIFICATION The
undersigned deposes and says that (s)he has duly executed the attached
application dated ________________, 19 ___, 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 the 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) FORM B INSURANCE
HOLDING COMPANY SYSTEM ANNUAL REGISTRATION STATEMENT Filed with the ALABAMA
DEPARTMENT OF INSURANCE BY ______________________________________ Name of
Registrant On Behalf of Following Insurance Companies: Name Address
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________ Date:
_______________________, 19 _____ Name, Title, Address and telephone number of
Individual To Whom Notices and Correspondence Concerning This Statement Should
Be Addressed:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________ ITEM 1.
IDENTITY AND CONTROL OF REGISTRANT 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.
ITEM 2. ORGANIZATIONAL CHART 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% of the total assets of the ultimate
controlling person within the insurance holding company system unless it has
assets valued at or exceeding $500,000. The chart or listing should shown 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 control. As to each person specified in the
chart or listing indicate the type of organization (e.g., - corporation, trust,
partnership) and the state or other jurisdiction of domicile. ITEM 3. THE
ULTIMATE CONTROLLING PERSON As to the ultimate controlling person in the
insurance holding company system furnish the following information: (a) Name;
(b) Home office address; (c) Principal executive office address; (d) The
organizational structure of the person, i.e., corporation, partnership,
individual, trust, etc.; (e) The principal business of the person; (f) The name
and address of any person who holds or owns 10% or more of any class of voting
security, the class of such security, the number of shares held of record or
known to be beneficially owned, and the percentage of class so held or owned;
(g) If court proceedings involving a reorganization or liquidation are pending,
indicate the title and location of the court, the nature of proceedings and the
date when commenced. ITEM 4. BIOGRAPHICAL INFORMATION 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 5 years, and any
conviction of crimes other than minor traffic violations during the past 10
years. ITEM 5. TRANSACTIONS AND AGREEMENTS 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: (a) Loans, other investments, or purchases, sales or exchanges of
securities of the affiliates by the Registrant or of the Registrant by its
affiliates; (b) Purchases, sales or exchanges of assets; (c) Transactions not
in the ordinary course of business; (d) Guarantees or undertakings for the
benefit of an affiliate which result in an actual contingent exposure of the
Registrant's assets to liability, other than insurance contracts entered into
in the ordinary course of the registrant's business; (e) All management
agreements, service contracts and all cost-sharing arrangements; (f)
Reinsurance agreements; (g) Dividends and other distributions to shareholders;
(h) Consolidated tax allocation agreements; and (i) Any pledge of the
registrant's stock and/or of the stock of any subsidiary or controlling
affiliate, for a loan made to any member of the insurance holding company
system. No information need be disclosed if such information is not material
for purposes of Section 4 of the Act. Sales, purchases, exchanges, loans or
extensions of credit, investments or guarantees involving one-half of 1% 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 the transaction, and relationship of the affiliated
parties to the registrant. ITEM 6. LITIGATION OR ADMINISTRATIVE PROCEEDINGS 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 is or was pending: (a) Criminal prosecutions or
administrative proceedings by any government agency or authority which may be
relevant to the trustworthiness of any party thereto; and (b) Proceedings which
may have a material effect upon the solvency or capital structure of the
ultimate holding company including, but not necessarily limited to, bankruptcy,
receivership or other corporate reorganizations. ITEM 7. STATEMENT REGARDING
PLAN OR SERIES OF TRANSACTIONS The insurer shall furnish a statement that
transactions entered into since the filing of the prior year's annual
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. ITEM 8. FINANCIAL STATEMENTS AND EXHIBITS (a)
Financial statements and exhibits should be attached to this statement as an
appendix, but list under this item the financial statements and exhibits so
attached. (b) The financial statements shall include the annual financial
statements of the ultimate controlling person in the insurance holding company
system as of the end of the person's latest fiscal year. 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 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 the insurer filed with the
insurance department of the insurer's domiciliary state and are in accordance
with requirements of insurance or other accounting principles prescribed or
permitted under the law and regulations of that state. (c) Exhibits shall
include copies of the latest annual reports to shareholders of the ultimate
controlling person and proxy material used by the ultimate controlling person;
and any additional documents or papers required by Form B or regulation
Sections 4 and 6. ITEM 9. FORM C REQUIRED A Form C, Summary of Registration
Statement, must be prepared and filed with this Form B. ITEM 10. SIGNATURE AND
CERTIFICATION Signature and certification required as follows: SIGNATURE
Pursuant to the requirements of Section 27-29-4, Code of Alabama 1975,
Registrant has caused this annual registration statement to be duly signed on
its behalf in the City of ______________________ and State of
___________________________ on the _____________ day of
__________________________, 19 ____. (Seal) ___________________________________
Name of Registrant BY ___________________________________ (Name) (Title)
Attest: __________________________________________ (Signature of Officer)
__________________________________________ (Title) CERTIFICATION The
undersigned deposes and says that (s)he has duly executed the attached annual
registration statement dated ______________________, 19 _________, 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) FORM C SUMMARY OF
REGISTRATION STATEMENT Filed with the ALABAMA DEPARTMENT OF INSURANCE BY
______________________________________ Name of Registrant On Behalf of
Following Insurance Companies: Name Address
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________ Date:
____________________________, 19 _____ Name, Title, Address and telephone
number of Individual To Whom Notices and Correspondence Concerning This
Statement Should Be Addressed:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________ Furnish a
brief description of all items in the current annual registration statement
which represent changes from the prior year's annual registration statement.
The description shall be in a manner as to permit the proper evaluation thereof
by the Commissioner, and shall include specific references to Item numbers in
the annual registration statement and to the terms contained therein. Changes
occurring under Item 2 of Form B insofar as changes in the percentage of each
class of voting securities held by each affiliate is concerned, need only be
included where such changes are ones which result in ownership or holdings of
10% or more of voting securities, loss or transfer of control, or acquisition
or loss of partnership interest. Changes occurring under Item 4 of Form B need
only be included where an individual is, for the first time, made a director or
executive officer of the ultimate controlling person; a director or executive
officer terminates his or her responsibilities with the ultimate controlling
person; or in the event an individual is named president of the ultimate
controlling person. If a transaction disclosed on the prior year's annual
registration statement has been changed, the nature of such change shall be
included. If a transaction disclosed on the prior year's annual registration
statement has been effectuated, furnish the mode of completion and any flow of
funds between affiliates resulting from the transaction. The insurer shall
furnish a statement that transactions entered into since the filing of the
prior year's annual registration statement are not part of a plan or series of
like transactions whose purpose it is to avoid statutory threshold amounts and
the review that might otherwise occur. SIGNATURE AND CERTIFICATION Signature
and certification required as follows: SIGNATURE Pursuant to the requirements
of Section 27-29-4, Code of Alabama 1975, the Registrant has caused this
summary of registration statement to be duly signed on its behalf in the City
of __________________ and State of ________________ on the ______ day of
______________, 19 ___. (SEAL) ____________________________________ Name of
Registrant By ____________________________________ (Name) (Title) CERTIFICATION
The undersigned deposes and says that (s)he has duly executed the attached
summary of registration statement dated _______________, 19 ___, for and on
behalf of _______________________________________ (Name of Company); 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) FORM D PRIOR NOTICE OF
A TRANSACTION Filed with the ALABAMA DEPARTMENT OF INSURANCE BY
______________________________________ Name of Registrant On Behalf of
Following Insurance Companies: Name Address
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________ Date:
____________________________, 19 _____ Name, Title, Address and telephone
number of Individual To Whom Notices and Correspondence Concerning This
Statement Should Be Addressed:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________ ITEM 1.
IDENTITY OF PARTIES TO TRANSACTION Furnish the following information for each
of the parties to the transaction: (a) Name; (b) Home office address; (c)
Principal executive office address; (d) The organizational structure, i.e.
corporation, partnership, individual, trust, etc.; (e) A description of the
nature of the parties' business operations; (f) Relationship, if any, of other
parties to the transaction to the insurer filing the notice, including any
ownership or debtor/creditor interest by any other parties to the transaction
in the insurer seeking approval, or by the insurer filing the notice in the
affiliated parties; (g) Where the transaction is with a non-affiliate, the
name(s) of the affiliate(s) which will receive, in whole or in substantial
part, the proceeds of the transaction. ITEM 2. DESCRIPTION OF THE TRANSACTION
Furnish the following information for each transaction for which notice is
being given: (a) A statement as to whether notice is being given under
provisions in the Act; (b) A statement of the nature of the transaction; and
(c) The proposed effective date of the transaction. ITEM 3. SALES, PURCHASES,
EXCHANGES, LOANS, EXTENSIONS OF CREDIT, GUARANTEES OR INVESTMENTS Furnish a
brief description of the amount and source of funds, securities, property or
other consideration for the sale, purchase, exchange, loan, extension of
credit, guarantee, or investment, whether any provision exists for purchase by
the insurer filing notice, by any party to the transaction, or by any affiliate
of the insurer filing notice, a description of the terms of any securities
being received, if any, and a description of any other agreements relating to
the transaction such as contracts or agreements for services, consulting
agreements and the like. If the transaction involves other than cash, furnish a
description of the consideration, its cost and its fair market value, together
with an explanation of the basis for evaluation. If the transaction involves a
loan, extension of credit or a guarantee, furnish a description of the maximum
amount which the insurer will be obligated to make available under such loan,
extension of credit or guarantee, the date on which the credit or guarantee
will terminate, and any provisions for the accrual of or deferral of interest.
If the transaction involves an investment, guarantee or other arrangement,
state the time period during which the investment, guarantee or other
arrangement will remain in effect, together with any provisions for extensions
or renewals of such investments, guarantees or arrangements. Furnish a brief
statement as to the effect of the transaction upon the insurer's surplus. No
notice need be given if the maximum amount which can at any time be outstanding
or for which the insurer can be legally obligated under the loan, extension of
credit or guarantee is less than (a) in the case of non-life insurers, the
lesser of 3% of the insurer's admitted assets or 25% of surplus as regards
policyholders, or (b) in the case of life insurers, 3% of the insurer's
admitted assets, each as of the 31st day of December next preceding. ITEM 4.
LOANS OR EXTENSION OF CREDIT TO A NON-AFFILIATE If the transaction involves a
loan or extension of credit to any person who is not an affiliate, furnish a
brief description of the agreement or understanding whereby the proceeds of the
proposed transaction, in whole or in substantial part, are to be used to make
loans or extensions of credit to, to purchase the assets of, or to make
investments in, any affiliate of the insurer making such loans or extensions of
credit, and specify in what manner the proceeds are to be used to loan to,
extend credit to, purchase assets of or make investments in any affiliate.
Describe the amount and source of funds, securities, property or other
consideration for the loan or extension of credit and, if the transaction if
one involving consideration other than cash, a description of its cost and its
fair market value together with an explanation of the basis for evaluation.
Furnish a brief statement as to the effect of the transaction upon the
insurer's surplus. No notice need be given if the loan or extension of credit
is one which equals less than, in the case of non-life insurers, the lesser of
3% of the insurer's admitted assets or 25% of surplus as regards policyholders
or, with respect to life insurers, 3% of the insurer's admitted assets, each as
of the 31st day of December next preceding. ITEM 5. REINSURANCE If the
transaction is a reinsurance agreement or modification thereto, furnish a
description of the known and/or estimated amount of liability to be ceded
and/or assumed in each calendar year, the period of time during which the
agreement will be in effect, and a statement whether an agreement or
understanding exists between the insurer and non-affiliate to the effect that
any portion of the assets constituting the consideration for the agreement will
be transferred to one or more of the insurer's affiliates. Furnish a brief
description of the consideration involved in the transaction, and a brief
statement as to the effect of the transaction upon the insurer's surplus. No
notice need be given for reinsurance agreements or modifications thereto if the
reinsurance premium or a change in the insurer's liabilities in connection with
the reinsurance agreement or modification thereto is less than 5% of the
insurer's surplus as regards policyholders, as of the 31st day of December next
preceding. ITEM 6. MANAGEMENT AGREEMENTS, SERVICE AGREEMENTS AND COST-SHARING
ARRANGEMENTS For management and service agreements, furnish: (a) A brief
description of the managerial responsibilities, or services to be performed;
(b) A brief description of the agreement, including a statement of its
duration, together with brief descriptions of the basis for compensation and
the terms under which payment or compensation is to be made. For cost-sharing
arrangements, furnish: (a) A brief description of the purpose of the agreement;
(b) A description of the period of time during which the agreement is to be in
effect; (c) A brief description of each party's expenses or costs covered by
the agreement; (d) A brief description of the accounting basis to be used in
calculating each party's costs under the agreement. ITEM 7. SIGNATURE AND
CERTIFICATION Signature and certification required as follows: SIGNATURE
Pursuant to the requirements of Section 4 of the Act, Registrant has caused
this annual registration statement to be duly signed on its behalf of the City
of ________________________________ and State of ______________________ on the
_____ day of _________________, 19 ____. (SEAL)
____________________________________________ Name of Applicant BY
________________________________________________ (Name) (Title) Attest:
___________________________________________________ (Signature of Officer)
__________________________________________________ (Title) CERTIFICATION The
undersigned deposes and says that (s)he has duly executed the attached annual
registration statement dated _______________, 19 ____, 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) Author:
Commissioner of Insurance Statutory Authority: Code of Ala. 1975, §§
27-2-17, 27-29-8. Revised: July 5, 1994; effective July 15, 1994. Filed for
codification in the Alabama Administrative Code by the Department of Insurance
on June 10, 2003, pursuant to the Code of Ala. 1975, § 27-7-43.
Amended by
Alabama
Administrative Monthly Volume XXXIII, Issue No. 11, August 31,
2015, eff. 1/1/2016.
Author: Commissioner of Insurance
Statutory Authority:
Code of Ala.
1975, §§
27-2-17,
27-29-8.
