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PDFWAC 284-18-930

Form C.

Filed with the Insurance Department of the State of
Name of Registrant
On Behalf of Following Insurance Companies
Date:                 , 20         
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 year's annual registration statement. The description must be in a manner as to permit the proper evaluation thereof by the commissioner, and must 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 the changes are ones which result in ownership or holdings of ten 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 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 the change must 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 it is to avoid statutory threshold amounts and the review that might otherwise occur.
Signature and certification required as follows:
Under the requirements of RCW 48.31B.025, the registrant has caused this summary of registration statement to be duly signed on its behalf in the City of              and State of        on the       day of          , 20      .
Name of Registrant
(Signature of Officer)
The undersigned deposes and says that (s)he has duly executed the attached summary of registration statement dated             , 20       , for and on behalf of (Name of Company ; that (s)he is the (Title of Officer) of the company and that (s)he is authorized to execute and file the 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.
(Type or print name beneath)
[Statutory Authority: RCW 48.02.060, 48.31B.040, chapter 48.31B RCW, and 2015 c 122. WSR 15-22-062 (Matter No. R 2015-05), § 284-18-930, filed 10/30/15, effective 1/1/16. Statutory Authority: RCW 48.02.060 and 1993 c 462 § 9. WSR 93-19-005 (Order R 93-9), § 284-18-930, filed 9/1/93, effective 10/2/93.]
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