Section 6.42. Initial statement of beneficial ownership of securities.

 

(1)   Persons required to file statements. A statement on Form 3 (shown at the end of this rule) of initial statement of beneficial ownership of securities is required to be filed by every person who is directly or indirectly the beneficial owner of more than 10% of any class of any equity security of a domestic stock insurance company, or who is a director or an officer of such a company.

(2)   When statements are to be filed.

(a) Beginning September 1, 1966, persons who hold any of the relationships specified in sub. (1) are required to file a statement within 10 days after assuming such relationship. Statements are not deemed to have been filed with the commissioner until they have actually been received by him or her.

(b) Persons who held any of the relationships specified in sub. (1) as of January 31, 1966, or who assumed such relationship(s) during the period of January 31, 1966 through August 31, 1966, are required to file such initial statement of beneficial ownership of securities by September 10, 1966.

(3)   Where statements are to be filed. One signed copy of each statement shall be filed with the commissioner of insurance, P.O. Box 7873, Madison, Wisconsin 53707-7873.

(4)   Separate statement for each company. A separate statement shall be filed with respect to the securities of each company.

(5)   Relation of reporting person to company. Indicate clearly the relationship of the reporting person to the company; for example,"Director", "Director and Vice President", "Beneficial owner of more than 10% of the company's stock", etc.

(6)   Date as of which beneficial ownership is to be given. The information as to beneficial ownership of securities shall be given as of January 31, 1966, or, in the case of persons who subsequently assume any of the relationships specified in sub. (1) , as of the date that relationship was assumed.

(7)   Title of security. The statement of the title of a security shall be such as clearly to identify the security even though there may be only one class; for example, "Class A Common Stock".

(8)   Nature of ownership. Under "Nature of ownership", state whether ownership of the securities is "direct" or "indirect". If the ownership is indirect, i.e., through a partnership, corporation, trust or other entity, indicate, in a footnote or other appropriate manner, the name or identity of the medium through which the securities are indirectly owned. The fact that securities are held in the name of a broker or other nominee does not, of itself, constitute indirect ownership. Securities owned indirectly shall be reported on separate lines from those owned directly and also from those owned through a different type of indirect ownership.

(9)   Statement of amount owned. In stating the amount of securities beneficially owned, give the face amount of debt securities or the number of shares or other units of other securities. In the case of securities owned indirectly, the entire amount of securities owned by the partnership, corporation, trust or other entity shall be stated. The person whose ownership is reported may, if he or she so desires, also indicate in a footnote, or other appropriate manner, the extent of his or her interest in the partnership, corporation, trust or other entity.

(10)   Inclusion of additional information. A statement may include any additional information or explanation deemed relevant by the person filing the statement.

(11)   Signature. If the statement is filed for a corporation, partnership, trust, etc., the name of the organization shall appear over the signature of the officer or other person authorized to sign the statement. If the statement is filed for an individual, it shall be signed by him or her or specifically on his or her behalf by a person authorized to sign for him or her.

History: Cr. Register, August, 1966, No. 128 , eff. 9-1-66; am. Register, September, 1976, No. 249 , eff. 10-1-76; corrections made under s. 13.93 (2m) (b) 5., Stats., Register, April, 1992, No. 436 . ________________________________________________
State of Wisconsin
Commissioner of Insurance
Form 3 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
(Filed pursuant to Wisconsin Administrative Code section Ins 6.42 )

(Name of insurance company)

(Name of person whose ownership is reported)

(Business address of such person; street, city, state, zip code)

Relationship of such person to company named above. (See s. Ins 6.42 (5) )

Date of event which requires the filing of this statement. (See s. Ins 6.42 (6) )

Securities Beneficially Owned - See PDF for table Remarks: (See s. Ins 6.42 (10) )
  I affirm under penalty of perjury that the       foregoing is full, true, and correct. Date of statement Signature