Section 3.21.060. Acquisition of control; statement filing; Form A.

    A person required to file a statement under AS 21.22.010 shall furnish the required information on Form A, made a part of this section in substantially the following form: 
 FORM A 
 STATEMENT REGARDING THE ACQUISITION OF CONTROL 
OF OR MERGER WITH A DOMESTIC INSURER 
________________________
              Name of Domestic Insurer 
                   By 
________________________
          Name of Acquiring Person (Applicant) 
Filed with the Insurance Division/Department of ____________ (State of domicile of insurer being acquired)  
Dated: ____________, 20____ 
Name, Title, Address, Electronic Mail Address, and Telephone Number of Individual to Whom Notices and Correspondence Concerning This Statement Should be Addressed: 
________________________
________________________
________________________
________________________
ITEM 1. INSURER AND METHODS OF ACQUISITION 
    State the name and address of the domestic insurer to which this application relates and a brief description of how control is to be acquired. 
ITEM 2. IDENTITY AND BACKGROUND OF THE APPLICANT 
  (a)  State the name and address of the applicant seeking to acquire control over the insurer. 
  (b)  If the applicant is not an individual, state the nature of its business operations for the past five years or for the lesser period as the person and any of that person's predecessors shall have been in existence. Briefly describe the business intended to be done by the applicant and the applicant's subsidiaries. 
  (c)  Furnish a chart or listing clearly presenting the identities of the interrelationships among the applicant and all affiliates of the applicant. Indicate in the chart or listing the percentage of voting securities of each person which is owned or controlled by the applicant or by any other person. If control of any person is maintained other than by the ownership or control of voting securities, indicate the basis of the control. As to each person specified in the chart or listing indicate the type of organization (e.g., corporation, trust, partnership) and the state or other jurisdiction of domicile. If court proceedings looking toward a reorganization or liquidation are pending with respect to any person, indicate which person, and set out the title of the court, nature of proceedings, and the date when commenced. 
ITEM 3. IDENTITY AND BACKGROUND OF INDIVIDUALS ASSOCIATED WITH THE APPLICANT 
    On the biographical affidavit, include a third-party background check and state the following with respect to (1) the applicant if the applicant is an individual or (2) all persons who are directors, executive officers, or owners of 10 percent or more of the voting securities of the applicant if the applicant is not an individual: 
  (a)  Name and business address; 
  (b)  Present principal business activity, occupation, or employment including position and office held and the name, principal business, and address of any corporation or other organization in which the employment is carried on; 
  (c)  Material occupations, positions, offices, or employment during the last five years, giving the starting and ending dates of each and the name, principal business, and address of the business corporation or other organization in which each occupation, position, office, or employment was carried on; if the occupation, position, office, or employment required licensing by or registration with any federal, state, or municipal governmental agency, indicate the fact, the current status of the licensing or registration, and an explanation of any surrender, revocation, suspension, or disciplinary proceedings in connection with the licensing or registration. 
  (d)  Whether or not the person has ever been convicted in a criminal proceeding, excluding minor traffic violations, during the last 10 years and, if so, give the date, nature of conviction, name and location of court, and penalty imposed or other disposition of the case. 
ITEM 4. NATURE, SOURCE AND AMOUNT OF CONSIDERATION 
  (a)  Describe the nature, source, and amount of funds or other considerations used or to be used in effecting the merger or other acquisition of control. If any part of the same is represented or is to be represented by funds or other consideration borrowed or otherwise obtained for the purpose of acquiring, holding, or trading securities, furnish a description of the transaction, the names of the parties to the transaction, the relationship, if any, between the borrower and the lender, the amounts borrowed or to be borrowed, and copies of all agreements, promissory notes and security arrangements relating to the transaction. 
  (b)  Explain the criteria used in determining the nature and amount of such consideration. 
  (c)  If the source of the consideration is a loan made in the lender's ordinary course of business and if the applicant wishes the identity of the lender to remain confidential, the applicant must specifically request that the identity be kept confidential. 
ITEM 5. FUTURE PLANS FOR INSURER 
    Describe any plans or proposals which the applicant may have to declare an extraordinary dividend, to liquidate the insurer, to sell its assets to or merge it with any person or persons, or to make any other material change in its business operations or corporate structure or management. 
ITEM 6. VOTING SECURITIES TO BE ACQUIRED 
    State the number of shares of the insurer's voting securities which the applicant, its affiliates, and any person listed in Item 3 plan to acquire, and the terms of the offer, request, invitation, agreement, or acquisition, and a statement as to the method by which the fairness of the proposal was arrived at. 
ITEM 7. OWNERSHIP OF VOTING SECURITIES 
    State the amount of each class of any voting security of the insurer which is beneficially owned or concerning which there is a right to acquire beneficial ownership by the applicant, its affiliates, or any person listed in Item 3. 
ITEM 8. CONTRACTS, ARRANGEMENTS, OR UNDERSTANDING WITH RESPECT TO VOTING SECURITIES OF THE INSURER 
    Give a full description of any contracts, arrangements, or understandings with respect to any voting security of the insurer in which the applicant, its affiliates, or any persons listed in Item 3 is involved, including transfer of any of the securities, joint ventures, loan or option arrangements, puts or calls, guarantees of loans, guarantees against loss or guarantees of profits, division of losses or profits, or the giving or withholding of proxies. The description must identify the persons with whom the contracts, arrangements, or understandings have been entered into. 
ITEM 9. RECENT PURCHASE OF VOTING SECURITIES 
    Describe any purchases of any voting securities of the insurer made by the applicant, its affiliates, or any person listed in Item 3 during the 12 calendar months preceding the filing of this statement. Include in the description the dates of purchase, the names of the purchasers, and the consideration paid or agreed to be paid for those securities. State whether any shares so purchased are hypothecated. 
ITEM 10. RECENT RECOMMENDATIONS TO PURCHASE 
    Describe any recommendations to purchase any voting security of the insurer made by the applicant, its affiliates, or any person listed in Item 3, or by anyone based upon interviews or at the suggestion of the applicant, its affiliates, or any person listed in Item 3 during the 12 calendar months preceding the filing of this statement. 
ITEM 11. AGREEMENTS WITH BROKER-DEALERS 
    Describe the terms of any agreement, contract, or understanding made with any broker-dealer as to solicitation of voting securities of the insurer for tender, and the amount of any fees, commissions, or other compensation to be paid to broker-dealers with regard to it. 
ITEM 12. FINANCIAL STATEMENTS AND EXHIBITS 
  (a)  Financial statements, exhibits, and three-year financial projections of each insurer must 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 persons identified in Item 2(c) for the preceding five fiscal years (or for the lesser period as the applicant, its affiliates, and any of its predecessors have been in existence), and similar information covering the period from the end of the person's last fiscal year, if the information is available. The statements may be prepared either on an individual basis, or, unless the director otherwise requires, on a consolidated basis if the consolidated statements are prepared in the usual course of business. The annual financial statements of the applicant must be accompanied by the certificate of an independent public accountant to the effect that the statements present fairly the financial position of the applicant 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 applicant is an insurer that is actively engaged in the business of insurance, the financial statements need not be certified, provided they are based on the annual statement of the person filed with the insurance department of the person's domiciliary state and are in accordance with the requirements of insurance or other accounting principles prescribed or permitted under the law and regulations of that state. 
  (c)  File as exhibits copies of all tender offers for, requests or invitations for, tenders of, exchange offers for, and agreements to acquire or exchange any voting securities of the insurer and (if distributed) of additional soliciting material relating to it; any proposed employment, consultation, advisory, or management contracts concerning the insurer; annual reports to the stockholders of the insurer and the applicant for the last two fiscal years; and any additional documents or papers required by Form A or by 3 AAC 21.010 and 3 AAC 21.030. 
ITEM 13. AGREEMENT REQUIREMENTS FOR ENTERPRISE RISK MANAGEMENT 
    Applicant agrees to provide, to the best of the applicant's knowledge and belief, the information required by Form F not later than 15 days after the end of the month in which the acquisition of control occurs. 
ITEM 14. SIGNATURE AND CERTIFICATION 
    Signature and certification are required as follows: 
 SIGNATURE 
    Under AS 21.22.010, ____________ (Name of Applicant) has caused this application to be duly signed on its behalf in the City or Community of ____________ and State of ____________ on the day of ____________, 20____. 
                    (SEAL) 
________________________
                    (Name of Applicant) 
________________________
                    (Name)                                            (Title) 
Attest: 
________________________
(Signature of Officer)
________________________
       (Title) 
 CERTIFICATION 
________________________
                    (Signature) 
________________________
                    (Type or print name below) 
________________________

Authorities

21.06.090;21.22.130

Notes

Authority

AS 21.06.090 AS 21.22.130

History

Eff. 6/30/77, Register 62; am 10/21/92, Register 124; am 11/26/2015, Register 216