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Title 3 . Commerce, Community, and Economic Development
Chapter 21 . Miscellaneous
Section 180. Summary of registration; statement filing; Form C

3 AAC 21.180. Summary of registration; statement filing; Form C

An insurer required to file a statement under AS 21.22.060 shall also furnish the required information on Form C, made a part of this section in substantially the following form:



Filed with the Insurance Division/Department of the State of ______________



(Name of Registrant)

On Behalf of the 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: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Furnish a brief description of all items in the current registration statement that represent changes from the most recently filed registration statement. The description shall be in a manner to permit the proper evaluation by the director, and shall include specific references to item numbers in the annual registration statement and to the terms contained in it. Changes occurring under Item 2 of Form B, to the extent that changes in the percentage of each class of voting securities held by each affiliate are concerned, need only be included where the changes are ones that result in ownership or holdings of 10 percent 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 when an individual is made a director or executive officer of the ultimate controlling person for the first time; a director's or executive officer's responsibilities for the ultimate controlling person are terminated; or an individual is named president, chief executive officer, treasurer, or chief financial officer of the ultimate controlling person. If a transaction disclosed on the prior year's annual registration statement has been changed, the nature of the change shall be included. If a transaction disclosed on the prior year's annual registration statement has been completed, furnish the mode of completion and any flow of funds between affiliates resulting from the transaction. The insurer shall furnish a statement affirming 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.


Signature and certification are required as follows:


Under AS 21.22.060 , the registrant has caused this summary of registration statement to be signed on its behalf in the City or Community of ____________ and State of ____________ on the day of ____________, 20____. (SEAL) ___________________________________________________________ (Name of Registrant) By ________________________________________________________ (Name) (Title) Attest: ________________________ (Signature of Officer) ________________________ (Title)


The undersigned deposes and says that (s)he has duly executed the attached summary of registration statement dated ____________, 20____, for and on behalf of ____________ (Name of Company); that (s)he is the ____________ (Title of Officer) of the company; and that (s)he is authorized to execute and file the instrument. Deponent further says that (s)he is familiar with the instrument and the contents of it and that the facts stated in it are true to the best of his/her knowledge, information, and belief. (Signature) ___________________________________________________________ (Type or print name below) __________________________________________________________

History: Eff. 10/21/92, Register 124

Authority: AS 21.06.090

AS 21.22.060

AS 21.22.130

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Last modified 7/05/2006