Section 855

Section 855.ILLUSTRATION A Form D-2

				FORM D-2

				GENERAL INSTRUCTIONS

Signature and Certification.

For purposes of filing the Form D-2, the signature and certification required by this Part shall be signed by an executive office of the insurer.


PRIOR NOTICE OF DIVIDENDS ON COMMON STOCK AND OTHER DISTRIBUTIONS

Filed with the Insurance Department of the State of Illinois

				By


			Name of Domestic Company

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 Request Should be Addressed:

Item 1. Type of Dividend or Distribution.

Identify the dividend or distribution as a dividend or other distribution subject to Section 131.16 of the Illinois Insurance Code [215 ILCS 131.16] or as an extraordinary dividend or other extraordinary distribution as defined in Section 131.20a(2) of the Illinois Insurance Code [215 ILCS 131.20a(2)].

Item 2. The amount of the dividend or other distribution and the date established for payment. The proposed date must be consistent with requirements for receipt of notice by the Department, as specified in Section 855.30(a) of 50 Ill. Adm. Code 855.

Item 3. A statement as to whether the dividend or other distribution is to be in cash or other property, and, if in property, a description thereof, its cost, statutory carrying value, and the fair market value of such property together with an explanation of the basis for valuation.

Item 4. The amounts and payment dates of all dividends paid within the period of 12 consecutive months ending on the date fixed for payment of the proposed dividend for which notification is being given or approval is being sought.

Item 5. An illustration of the calculation of the extraordinary dividend limit set by Section 131.20a of the Illinois Insurance Code. Dividends that have been or will be paid in other than cash, shall be valued for the purposes of the calculation at the greater of market or statutory carrying value of the asset.

Item 6. If the notice is filed for an extraordinary dividend pursuant to Section 131.20a of the Illinois Insurance Code, the following items must also be included:

a) A balance sheet and statement of income for the period intervening from the last annual statement filed with the Director and the end of the month preceding the month in which the prior notification of the dividend is submitted. Indicate the amount of all unrealized capital gains included in unassigned funds.

b) A brief statement as to the effect of the proposed dividend upon the insurer's surplus and the reasonableness of surplus in relation to the insurer's outstanding liabilities and the adequacy of surplus relative to the insurer's financial position.

c) A calculation of the insurer's risk based capital level as of the most recently filed financial statement (quarterly or annual), adjusted to show the effect of the proposed dividend or other distribution.

Pursuant to the requirements of Section 131.16 (or 131.6 and 131.20a, in the case of extraordinary

dividends) 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

(Name)

(Title)

Attest:

(Signature of Officer)

(Title)

CERTIFICATION

The undersigned deposes and says that (s)he had duly executed the attached notice dated

for and on behalf of

;

that (s)he is the

(Name of Insurer)

of such company and that (s)he is familiar with such

(Title of Officer)

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 21 Ill. Reg. 5922, effective April 29, 1997)