Section 854.ILLUSTRATION A   Form D-1

 

FORM D-1

 

GENERAL INSTRUCTIONS

 

A.        Signature and Certification

            For purposes of filing the Form D-1, the signature and certification required by this Part shall be signed by an executive officer of the insurer requesting the Director's approval.

 

B.         Copy of the Transaction Agreement

            A copy of the proposed transaction agreement shall be attached to the Form D-1 filing as Exhibit A.  If the agreement is in other than final form, it shall be so identified.

 

PRIOR NOTICE OF A TRANSACTION

 

Filed with the Insurance Department of the State of Illinois

 

By

 

 

On Behalf of the Following Insurance Companies:

 

Name	Address

 

Date: _________________,  19 ___

 

Name, Title, Address and Telephone Number of Individual to Whom Notices and Correspondence Concerning this Request Should Be Addressed:

 

 

 

Item 1.             Identity of Parties to the 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 proposed transaction. For purposes of this subsection, substantial part means an amount which would trigger disclosure if given directly to the affiliate.

 

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 Section 131.20a(1)(a)(i), (ii), (iii), (iv), or (v) of the Illinois Insurance Code. At the time of adoption of this rulemaking, the Department has not adopted a rule under subsection (v) above.

 

b)         A brief description of the nature and purpose of the transaction.

 

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, 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 borrowed funds are to be used by the insurer identify the lender, any collateral requirements, interest due dates, interest rates, and principal payment due date.

 

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.

 

Item 4. Loans or Extensions 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 is 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.

 

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 description of any agreement or understanding that exists between the insurer and a 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.

 

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 cost under the agreement.

 

 

Pursuant to the requirements of Section 131.20a of the Illinois Insurance Code,
has caused this notice to be duly signed on its behalf in the City of											and State
of		on the		day of			, 19			.

 

 

 

 

 

	Name of Requesting Insurer
By
	(Name)	(Title)

 

 

Attest:

 

 

 

 

(Signature of Officer)

(Title)

 

 

CERTIFICATION

 

The undersigned deposes and says that (s)he has duly executed the attached notice dated
	,  19		, for and on behalf of			; that (s)he is the
					(Name of Insurer)
		of such company and that (s)he is authorized to execute and file such
(Title of Officer)

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 beneath)

 

(Source:  Amended at 18 Ill. Reg. 6176, effective April 6, 1994)