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INSURANCE HOLDING COMPANY SYSTEM ANNUAL REGISTRATION STATEMENT MATTHEW (Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor)

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STATE OF MONTANA
MATTHEW M. ROSENDALE, SR.
COMMISSIONER OF SECURITIES & INSURANCE
Office of the Montana State Auditor
PO BOX 4009
HELENA, MT 59604
406-444-2040
FORM B
INSURANCE HOLDING
COMPANY SYSTEM
ANNUAL REGISTRATION
STATEMENT
Filed with the Department of Insurance of the state of Montana
By
Name of Registrant
On Behalf of 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:
ITEM 1. IDENTITY AND CONTROL OF REGISTRANT
Furnish the exact name of each insurer registering or being registered (hereinafter called
"the Registrant") , the home office address and principal executive offices of each; the date
on which each registrant became part of the insurance holding company system; and the
method(s) by which control of each registrant was acquired and is maintained.
ITEM 2. ORGANIZATIONAL CHART
Furnish a chart or listing clearly presenting the identities of all interrelationships among all
affiliated persons within the insurance holding company system. No affiliate need be
shown if its total assets are equal to less than 1/2 of 1% of the total assets of the ultimate
controlling person within the insurance holding company system unless it has assets
valued at or exceeding (insert amount) . The chart or listing should show the percentage of
each class of voting securities of each affiliate which is owned, directly or indirectly, by
another affiliate. If control of any person within the system is maintained other than by the
ownership or control of voting securities, indicate the basis of such control. As to each
person specified in such chart or listing, indicate the type of organization (e.g., corporation,
trust, partnership) and the state or other jurisdiction of domicile.
ITEM 3. THE ULTIMATE CONTROLLING PERSON
As to the ultimate controlling person in the insurance holding company system furnish the
following information:
(a) Name.
(b) Home office address.
(c) Principal executive office address.
(d) The organizational structure of the person, i.e., corporation, partnership, individual,
trust, etc.
(e) The principal business of the person.
(f) The name and address of any person who holds or owns 10% or more of any class of
voting security, the class of such security, the number of shares held of record or
known to be beneficially owned, and the percentage of class so held or owned.
(g) If court proceedings involving a reorganization or liquidation are pending, indicate the
title and location of the court, the nature of proceedings, and the date when
commenced.
ITEM 4. BIOGRAPHICAL INFORMATION
Furnish the following information for the directors and executive officers of the ultimate
controlling person: the individual's name and address, his or her principal occupation, and
all offices and positions held during the past five years, and any conviction of crimes other
than minor traffic violations during the past ten years.
ITEM 5. TRANSACTIONS AND AGREEMENTS
Briefly describe the following agreements in force and transactions currently outstanding or
which have occurred during the last calendar year between the registrant and its affiliates:
(a) loans, other investments, or purchases, sales, or exchanges of securities of the
affiliates by the registrant or of the registrant by its affiliates;
(b) purchases, sales,' or exchanges of assets;
(c) transactions not in the ordinary course of business;
(d) guarantees or undertakings for the benefit of an affiliate which result in an actual
contingent exposure of the registrant's assets to liability, other than insurance contracts
entered into in the ordinary course of the registrant's business;
(e) all management agreements, service contracts, and all cost-sharing arrangements;
(f) reinsurance agreements;
(g) dividends and other distributions to shareholders;
(h) consolidated tax allocation agreements; and
(i) any pledge of the registrant's stock and/or of the stock of any subsidiary or controlling
affiliate, for a loan made to any member of the insurance holding company system.
No information need be disclosed if such information is not material for purposes of
Section 4 of the Act.
Sales, purchases, exchanges, loans or extensions of credit, investments or guarantees
involving one-half of 1% or less of the registrant's admitted assets as of the 31st day of
December next preceding are not deemed material. (Note: Commissioner may by rule or
order provide otherwise.)
The description must be in a manner as to permit the proper evaluation thereof by the
commissioner, and shall include at least the following: the nature and purpose of the
transaction, the nature and amounts of any payments or transfers of assets between the
parties, the identity of all parties to such transaction, and relationship of the affiliated
parties to the registrant.
ITEM 6. LITIGATION OR ADMINISTRATIVE PROCEEDINGS
A brief description of any litigation or administrative proceedings of the following types,
either then pending or concluded within the preceding fiscal year, to which the ultimate
controlling person or any of its directors or executive officers was a party or of which the
property of any such person is or was the subject; give the names of the parties and the
court or agency in which such litigation or proceeding is or was pending:
(a) Criminal prosecutions or administrative proceedings by any government agency or
authority which may be relevant to the trustworthiness of any party thereto; and
(b) Proceedings which may have a material effect upon the solvency or capital structure of
the ultimate holding company including, but not necessarily limited to, bankruptcy,
receivership, or other corporate reorganizations.
ITEM 7. STATEMENT REGARDING PLAN OR SERIES OF TRANSACTIONS
The insurer shall furnish a statement that transactions entered into since the filing of the
prior year's annual 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.
ITEM 8. FINANCIAL STATEMENTS AND EXHIBITS
(a) Financial statements and exhibits should be attached to this statement as an appendix,
but list under this item the financial statements and exhibits so attached.
(b) The financial statements must include the annual financial statements of the ultimate
controlling person in the insurance holding company system as of the end of the
person's latest fiscal year.
If at the time of the initial registration, the annual financial statements for the latest
fiscal year are not available, annual statements for the previous fiscal year may be filed
and similar financial information must be filed for any subsequent period to the extent
such information is available. Such financial statements may be prepared on either an
individual basis, or unless the commissioner otherwise requires, on a consolidated
basis if such consolidated statements are prepared in the usual course of business.
Unless the commissioner otherwise permits, the annual financial statements must be
accompanied by the certificate of an independent public accountant to the effect that
such statements present fairly the financial position of the ultimate controlling person
and the results of its operations for the year then ended, in conformity with generally
accepted accounting principles or with requirements of insurance or other accounting
principles prescribed or permitted under law. If the ultimate controlling person is an
insurer which is actively engaged in the business of insurance, the annual financial
statements need not be certified, provided they are based on the Annual Statement of
such insurer filed with the insurance department of the insurer's domiciliary state and
are in accordance with requirements of insurance or other accounting principles
prescribed or permitted under the law and regulations of such state.
(c) Exhibits must include copies of the latest annual reports to shareholders of the ultimate
controlling person and proxy material used by the ultimate controlling person; and any
additional documents or papers required by Form B or Regulation Sections 4 and 6.
ITEM 9. FORM C (TO BE FILED WITH FORM B)
A Form C, Summary of Registration Statement, must be prepared and filed with this Form
B.
ITEM 10. SIGNATURE AND CERTIFICATION
Signature and certification required as follows:
SIGNATURE
Pursuant to the requirements of section 33-2-1111,
MCA, has caused this notice to be duly signed on its
behalf in the city of
and state of on the day of
(SEAL)
Name of Applicant
By
(Name) (Title)
Attest:
(Signature of Officer)
(Title)
,
20
.
he is the
CERTIFICATION
The undersigned certifies that (s)he has duly executed the attached notice dated
, 20 , for and on behalf of
(Name of Applicant) of
such company and that (s)he
(Title of officer)
Is authorized to execute and file such 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)
STATE OF MONTANA
MATTHEW M. ROSENDALE, SR.
COMMISSIONER OF SECURITIES & INSURANCE
Office of the Montana State Auditor
PO BOX 4009
HELENA, MT 59604
406-444-2040
FORM C
SUMMARY OF
REGISTRATION
STATEMENT
Filed with the Department of Insurance of the state of Montana
By
Name of Registrant
On Behalf of Following Insurance Companies
Name Address
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 annual registration statement which
represent changes from the prior years annual registration statement. The description
shall be in a manner as to permit the proper evaluation thereof by the commissioner,
and shall include specific references to Item numbers in the annual registration
statement and to the terms contained therein.
Changes occurring under Item 2 of Form B insofar as changes in the percentage of
each class of voting securities held by each affiliate is concerned, need only be
included where such changes are ones which 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
where: an individual is, for the first time, made a director or executive officer of the
ultimate controlling person; a director or executive officer terminates his or her
Date:
, 20
day of
,
20
.
he is the
responsibilities with the ultimate controlling person; or in the event an individual is
named president of the ultimate controlling person.
If a transaction disclosed on the prior year's annual registration statement has been
changed, the nature of such change shall be included. If a transaction disclosed on the
prior year's annual registration statement has been effectuated, furnish the mode of
completion and any flow of funds between affiliates resulting from the transaction.
The insurer must furnish a statement that transactions entered into since the filing of the
prior year's annual registration statement are not part of a plan or series of like
transactions whose purpose is to avoid statutory threshold amounts and the review that
might otherwise occur.
Signature and certification required as follows:
SIGNATURE
Pursuant to the requirements of section 33-2-1111, MCA, has
caused this notice to be duly signed on its behalf in the city of
and state of on the
(SEAL)
Name of Applicant
By
(Name) (Title)
Attest:
(Signature of Officer)
(Title)
CERTIFICATION
The undersigned certifies that (s)he has duly executed the attached notice dated
, 20 , for and on behalf of
(Name of Applicant) of
such company and that (s)he
(Title of officer)
Is authorized to execute and file such 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)
STATE OF MONTANA
MATTHEW M. ROSENDALE, SR.
COMMISSIONER OF SECURITIES & INSURANCE
Office of the Montana State Auditor
PO BOX 4009
HELENA, MT 59604
406-444-2040
FORM F
ENTERPRISE RISK
REPORT
Filed with the Office of the Montana State Auditor, Commissioner of Securities and
Insurance
By
Name of Registrant/Applicant
On Behalf of/Related to 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:
ITEM 1. ENTERPRISE RISK
The Registrant/Applicant, to the best of its knowledge and belief, shall provide
information regarding the following areas that could produce enterprise risk as
defined in 33-2-1101(3), MCA, provided such information is not disclosed in the
Insurance Holding Company System Annual Registration Statement filed on
behalf of itself or another insurer for which it is the ultimate controlling person:
• Any material developments regarding strategy, internal audit findings,
compliance or risk management affecting the insurance holding company system;
• Acquisition or disposal of insurance entities and reallocating of existing
financial or insurance entities within the insurance holding company system;
• Any changes of shareholders of the insurance holding company system
exceeding ten percent (10%) or more of voting securities;
• Developments in various investigations, regulatory activities or litigation that
may have a significant bearing or impact on the insurance holding company system;
• Business plan of the insurance holding company system and summarized
strategies for next 12 months;
• Identification of material concerns of the insurance holding company system
raised by supervisory college. if any, in last year;
• Identification of insurance holding company system capital resources and
material distribution patterns;
• Identification of any negative movement, or discussions with rating agencies
which may have caused. or may cause, potential negative movement in the credit ratings
and individual insurer financial strength ratings assessment of the insurance holding
company system (including both the rating score and outlook);
• Information on corporate or parental guarantees throughout the holding
company and the expected source of liquidity should such guarantees be called upon ; and
• Identification of any material activity or development of the insurance holding
company system that, in the opinion of senior management, could adversely affect the
insurance holding company system.
The Registrant/Applicant may attach the appropriate form most recently filed with the
U.S. Securities and Exchange Commission, provided the Registrant/Applicant includes
specific references to those areas listed in Item 1 for which the form provides
responsive information. If the Registrant/Applicant is not domiciled in the U.S., it may
attach its most recent public audited financial statement filed in its country of domicile,
provided the Registrant/Applicant includes specific references to those areas listed in
Item 1 for which the financial statement provides responsive information.
ITEM 2: OBLIGATION TO REPORT.
If the Registrant/Applicant has not disclosed any information pursuant to Item 1,
the Registrant/Applicant shall include a statement affirming that to the best of its
knowledge and belief, it has not identified enterprise risk subject to disclosure
pursuant to Item.
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INSURANCE HOLDING COMPANY SYSTEM ANNUAL REGISTRATION STATEMENT MATTHEW (Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor)

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Completed 20 July 2020

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