Section 853.ILLUSTRATION A   Form CX FORM CX

INSTRUCTIONS FOR COMPLETION

FORM CX

PRE-ACQUISITION NOTIFICATION

Filed with the Insurance Department of the State of Illinois.

BY

On Behalf of the Following Insurance Companies

Name, Title and Address of Officer to Whom Notices and Correspondence Concerning this Statement Should be Addressed: ___________________________________________________

Item 1.             Parties.

Identify all "involved insurers", "acquired persons" or "acquired insurers" subject to Section 131.12a of the Illinois Insurance Code.

Item 2.             Method and date of acquisition.

Describe the transaction(s) which will occur which may directly or indirectly change the control as defined in Section 131.1(b) of the Illinois Insurance Code (Ill. Rev. Stat. 1985, ch. 73, par. 743.1) of an insurer authorized to do business in this State.  Identify the effective date for the transaction(s).

Item 3.             Market Shares.

            Identify the rank and percent of the market share for each insurer or group of insurers as defined by Section 131.12a by line of insurance.  The lines of insurance include Illinois business reported on page 46 of the Life, Accident and Health Annual Statement blank and page 14 of the Fire and Casualty Annual Statement blank as filed with the Director for the preceding year as required by Section 136 of the Illinois Insurance Code (Ill. Rev. Stat. 1985, ch. 73, par. 748).

Item 4.             Expert Opinion (Optional).

            Include statement by economist regarding competitive impact of acquisition.  Such statement shall also include the qualifications of said economist.

Item 5.             Filing Fees.

            Pursuant to Section 408 of the Illinois Insurance Code (Ill. Rev. Stat. 1985, ch. 73, par. 1020), the Director shall collect a fee for the filing of a statement of acquisition of a foreign or alien insurance company. This filing shall not be deemed complete until the Director has received the appropriate filing fee as required by Section 408.

Item 6.             This Form is not to be used as a blank form to be filled in, but only as a guide in the preparation of the statement.

Affidavit of Registrant.

(Company officer) ________________________ being duly sworn, deposes and says:

That he is the _____(Title)_____ of the _____(Name of the Company)_____, a corporation organized and existing under and by virtue of the laws of the State of _____(State)_____; and on whose behalf makes this Affidavit.

Deponent says that he is familiar with Pre-Acquisition Notification and the contents thereof, and that the facts set forth are true to the best of his knowledge, information and belief.

____________________________________

(Signature)

(Type or Print Name Beneath)