(a) The following
forms shall be used pursuant to this article:
(1) Certificate of Compliance:
VARIABLE CONTRACT CERTIFICATE OF
COMPLIANCE
Name of Applicant Company:
Address:
Date:
Person to Whom Correspondence Should Be Addressed:
(Directions: This Certificate may be utilized in lieu of
applicant seeking a prior approval of its changes in its variable contract
operation; such an approval being based upon a full review by the Department.
This Certificate must be executed by an executive officer of the applicant, who
has responsibility for applicant's variable contract operation. Please answer
each question in the accompanying Forms completely. If more room is needed,
attach a sheet of paper indicating the question being responded to.)
TO THE INSURANCE COMMISSIONER OF THE STATE OF
CALIFORNIA
I, [____________________], a duly appointed executive
officer of the Applicant Company, having responsibility for its variable
contract operation, do state, under oath, that I have carefully read this
Certification and the attached Forms, and that the information and answers to
questions herein is true to the best of my own knowledge, except as to those
specifically stated to be upon information and belief, and as to those I
believe the answers to be true.
Further I state that the variable contract changes
described herein comply with pertinent statutes, regulations, and bulletins,
and have been reviewed by me, or that I have been advised by competent legal
counsel, representing the company, that the changes are in full compliance with
the California Insurance Code, Regulations, Bulletins, and underlying
guidelines. In particular, I state that this filing complies with Title 10
California Code of Regulations sections
2534.40-2534.46.
All material changes occurring since my company's most
recent amendment of its variable contract qualification, (and the approval or
acknowledgment by the Department of that amendment), are explained and
described herein, or in accompanying materials and documentation. The
information given here does not relate to any changes previously submitted to
the Department and disapproved by the Department, unless corrective action has
been taken by my company to meet the objections previously stated by the
Department to those changes.
I understand and acknowledge that false statements which
are intended to mislead or deceive the Commissioner, or the willful omission of
any material fact with the same intent, may be punishable under such sections
of the Insurance Code as may be applicable.
WITNESS MY SIGNATURE this [__________] day of [__________],
[___], at [__________].
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SUBSCRIBED AND SWORN TO before me on the date and year
above written.
[________________________________________]
(Notary Public in and for said County and State)
My commission expires [_______________]
(2) New Matters Form:
DESCRIPTION OF NEW MATTERS FORM
1.
Background Information:
a. Applicant's name:
b. Applicant's state of domicile:
c. Date of applicant's California Certificate
of Authority:
d. Date of
applicant's original qualification for California Variable Authority:
e. Date and type of applicant's last
amendment to its California Variable Authority:
f. What variable products is the applicant
currently offering in California?
g.
Has the applicant ever been subject to a regulatory disciplinary action, at
either a state or federal level, for actions arising out of its variable
annuity or variable life business? If yes, identify each
action:
2. What amendments
to the applicant's current variable qualification are being requested in this
application? (Be sure to include a new product form, new fund form, new
subaccount/portfolio form and/or other material changes form for each
applicable amendment).
a. New
Product:
b. New Fund:
c. New Subaccount/Portfolio:
d. Other Material
Changes:
3. Has the
applicant included an original certificate of compliance?
4. Please identify the type(s) of investments
presented in this application (for example):
a. Mutual Fund (2534.42 (b)(1))
b. ERISA or Other Plan
(2534.42.(b)(2))
c. California
Insurance Code Section
10506.3
Product (2534.42(b)(3))
d. Issued
to a trust under California Insurance Code Section
10541
(2534.42(b)(4)
e. Private Placement
(2534.42(b)(5))?
5. If the
amendments set forth in the application require a filing with the Securities
and Exchange Commission, the application must include an effective prospectus
and statement of additional information. Applications for amended
variable qualification will not be accepted for filing until an effective
prospectus has been submitted.
6. If the amendments set forth in the
application do not require a filing with the Securities and Exchange
Commission, the application must include a private placement memorandum or
comparable disclosure documentation available to purchasers of the product(s).
Applications for amended variable qualification will not be accepted for
filing until disclosure documents have been
submitted
(3) New
Product Form
NEW PRODUCT FORM
1.
PRODUCT NAME: What is the
name of the New Product?
2.
PRODUCT DESCRIPTION: Provide a brief description of the New
Product.
3.
POLICY
FORM: Attach a specimen copy of the New Product policy form.
4.
MARKETING: How will this new
product be marketed? Who will be the target market for this new product? Attach
copies of any advertising or marketing information that will be distributed to
the applicant's marketing agents and/or sales force.
5.
DISTRIBUTION: How will the
New Product be distributed? Will a third party handle distribution? If yes,
attach a copy of the distribution agreement.
6.
ADMINISTRATION: Will the
administration of this New Product be delegated to a third party? If yes,
attach a copy of the administration agreement. Administration of a life or
annuity product by a third party will require a third party administrator's
license (California Insurance Code Section
1759).
7.
SALES COMMISSION: What is the
sales commission on this New Product?
8.
SURRENDER CHARGE: What is the
surrender charge on the New Product?
9.
CONTRACT FEE: What is the
annual contract fee on this New Product?
10.
MORTALITY AND EXPENSE RISK
CHARGES: What are the mortality and expense risk charges on this New
Product?
11.
PRODUCT
PROSPECTUS AND STATEMENT OF ADDITIONAL INFORMATION: Does this new
product require the filing of a prospectus with the Securities and Exchange
Commission? If yes, attach a copy of the product prospectus and statement of
additional information. (All insurers must provide an effective product
prospectus and statement of additional information before an application to
amend their variable qualification will be accepted for filing).
12.
PLAN DOCUMENTS: If this New
Product is not subject to filing with the Securities and Exchange Commission,
attach a copy of the Plan Documents or other documentation which provides
information about the new product.
(4) New Fund Form:
NEW FUND FORM
1.
FUND NAME: What is the name
of the New Fund?
2.
INVESTMENT ADVISOR: Who is the investment advisor for the new
fund? Attach a copy of the investment advisory agreement.
3.
DISTRIBUTOR: Who is the
distributor (broker/dealer) for the New Fund?
4.
USE OF FUND(S) BY OTHER INSURANCE
COMPANIES: Has this New Fund ever been qualified for use in California
as an investment for variable products? If yes, please provide the names of the
insurance companies you know are qualified to offer this fund.
5.
DISCIPLINARY ACTIONS: Has
this New Fund, its investment advisor or its broker-dealer been subject to any
disciplinary action by the Securities and Exchange Commission, the California
Department of Corporations or any other State securities regulator, the
National Association of Securities Dealers or any other self-regulatory
organizations, or the Commodities Futures Trading Commission within the past
ten years? If yes, attach a copy of each action.
6.
FUND PROSPECTUS AND STATEMENT OF
ADDITIONAL INFORMATION: Does this New Fund require a filing with the
Securities and Exchange Commission? If yes, attach a copy of the effective fund
prospectus and statement of additional information. The fund prospectus and
statement of additional information must be effective before the application
for amended variable qualification will be accepted for filing.
7.
PLAN DOCUMENTS: If the New
Fund is not subject to filing with the Securities and Exchange Commission,
attach a copy of the Plan Documents or other documentation which provides
information about the New Fund.
(5) New Subaccount Form:
NEW SUBACCOUNT FORM
1.
SUBACCOUNT NAME: What is the
name of the New Subaccount?
2.
INVESTMENT OBJECTIVE: What is the principal investment objective
of the New Subaccount?
3.
SUBACCOUNT MANAGER: Who is the Subaccount manager for the New
Subaccount?
4.
FEES:
Are any fees charged by the New Subaccount? If yes, identify each
charge.
5.
DISCIPLINARY
ACTIONS: Has the New Subaccount or its portfolio manager been subject to
any disciplinary action by the Securities and Exchange Commission, the
California Department of Corporations or any other State securities regulator,
the National Association of Securities Dealers or any other self-regulatory
organizations, or the Commodities Futures Trading Commission within the past
ten years? If yes, attach a copy of the action.
6.
PROSPECTUS AND STATEMENT OF
ADDITIONAL INFORMATION: Does the New Subaccount require a filing with
the Securities and Exchange Commission? If yes, attach a copy of the effective
product and/or fund prospectus and statement of additional information relating
to the addition of this New Subaccount. The product and/or fund prospectus must
be effective before the application for amended variable qualification will be
accepted for filing.
7.
PLAN
DOCUMENTS OR OTHER INFORMATIONAL MATERIAL: If the New Subaccount is not
subject to Securities and Exchange Commission filing, attach a copy of the Plan
Documents or other informational material which provides information about the
subaccount/portfolio.
(6)
Other Material Changes Form:
OTHER MATERIAL CHANGES
1.
OTHER MATERIAL CHANGES:
Identify any material changes to the applicant's current variable
qualification.
(Examples of material changes are as follows:
1) change of custodian;
2) change of administrator;
3) change of broker/dealer;
4) change of investment advisor;
5) change of portfolio manager;
6) change in fund or portfolio
name;
7) change in fund or
portfolio investment objective;
8)
disciplinary action taken by the Securities and Exchange Commission, the
California Department of Corporations or any other State securities regulator,
the National Association of Securities Dealers or any other self-regulatory
organizations, or the Commodities Futures Trading Commission against fund,
investment advisor, portfolio manager or broker/dealer;
9) regulatory action against the insurer
arising out of its variable annuity or variable life business;
10) amendments to:
a) the Board of Directors
resolutions,
b) the agreement
establishing the separate account,
c) the variable contract, or
d) registration statement or prospectus; and
11) any substantial change in management of the Separate
Account).
2.
PROSPECTUS AND STATEMENT OF ADDITIONAL INFORMATION: If filing with
the Securities and Exchange Commission is required for any of the changes
listed above, attach a copy of the effective prospectus and statement of
additional information which reflects these changes.
3.
PLAN DOCUMENTS: If filing
with the Securities and Exchange Commission for any of the changes identified
above is not required, attach a copy of the Plan Documents or other
documentation which provides information about these
changes.
