Insurance Holding Company System

TO STATE OF FLORIDA INSURANCE COMMISSIONER

INSURANCE HOLDING COMPANY SYSTEM

REGISTRATION STATEMENT

OF

__________________________________________________________________

(State name of Insurer)

and

_______________________________________________________________________________________

(Name above all Florida domestic insurer members of the holding company system)

_______________________________________________________________________________________

(Name above all admitted foreign insurer members of the holding company system)

The Registrant(s) hereby report(s) to the Insurance Commissioner for the purpose of registering as required by rule 4-143.046 of Insurance Department as follows:

ITEM I

Describe the corporate and the capital structure of the insurer and all its affiliates. Attach financial statements if not incorporated by reference in accordance with rule 4-143.048.

ITEM II

Identify the ownership and management of the insurer and all of its affiliates; include each person who is directly or indirectly the beneficial owner of more than 5% of any class of any equity security or who is a director or officer of the insurer and any of its affiliates.

ITEM III

List all of the following agreements in force relationships subsisting, and transactions currently outstanding between such insurer and its affiliates:

(1) loans other investments, or purchases, sales or exchanges of securities of the affiliates by the insurer by its affiliates;

(2) purchases, sales or exchanges of assets;

(3) transactions not in the ordinary course of business;

D14-516

(4) guarantee or undertakings for the benefit of an affiliate which result in an actual contingent exposure or the insurer's assets to liability, other than insurance contracts entered into in the ordinary course of the insurance's business.

(5) all management and service contracts and all cost-sharing arrangements, other than cost allocation arrangements based upon generally accepted accounting principles; and

(6) reinsurance agreements covering all of one or more lines of insurance of the ceding company.

ITEM IV

Furnish the following information with regard to each employment contract entered into by the insurer and each of its affiliates with any of the officers and/or directors of the insurer: name of employees; position held, annual remuneration, and other perquisites, and term of contract.

ITEM V

Furnish a brief description of any litigation or administrative proceedings of the following types, either than pending or concluded within the preceding fiscal year, to which any person reporting herewith 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 or any party thereto; and

(b) proceedings which may have material effect upon the solvency or capital structure of any admitted insurer member of the holding company system including, by not necessarily limited to, bankruptcy, receivership, other corporate reorganizations, and litigation drawing in question the validity of the issued and outstanding shares of any such admitted or nonadmitted insurer member.

I have reviewed the above, and to the best of my knowledge, information and belief, its true and correct.

__________________ ________________________ _______________________

Date Name Position or Title

sworn to and Subscribed before me this ____________day of______________________________, 20___

____________________________________________

Notary Public

(SEAL)

OIR-C0-516

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