Cal. Code Regs. tit. 10, § 2534.46 – Forms.

(a) The following forms shall be used pursuant to this article:
1. (1) Certificate of Compliance:
  VARIABLE CONTRACT CERTIFICATE OF COMPLIANCE
  Name of Applicant Company:
  Address:
  Date:
  Person to Whom Correspondence Should Be Addressed:
  (Directions: This Certificate may be utilized in lieu of applicant seeking a prior approval of its changes in its variable contract operation; such an approval being based upon a full review by the Department. This Certificate must be executed by an executive officer of the applicant, who has responsibility for applicant's variable contract operation. Please answer each question in the accompanying Forms completely. If more room is needed, attach a sheet of paper indicating the question being responded to.)
  TO THE INSURANCE COMMISSIONER OF THE STATE OF CALIFORNIA
  I, [____________________], a duly appointed executive officer of the Applicant Company, having responsibility for its variable contract operation, do state, under oath, that I have carefully read this Certification and the attached Forms, and that the information and answers to questions herein is true to the best of my own knowledge, except as to those specifically stated to be upon information and belief, and as to those I believe the answers to be true.
  Further I state that the variable contract changes described herein comply with pertinent statutes, regulations, and bulletins, and have been reviewed by me, or that I have been advised by competent legal counsel, representing the company, that the changes are in full compliance with the California Insurance Code, Regulations, Bulletins, and underlying guidelines. In particular, I state that this filing complies with Title 10 California Code of Regulations sections 2534.40-2534.46.
  All material changes occurring since my company's most recent amendment of its variable contract qualification, (and the approval or acknowledgment by the Department of that amendment), are explained and described herein, or in accompanying materials and documentation. The information given here does not relate to any changes previously submitted to the Department and disapproved by the Department, unless corrective action has been taken by my company to meet the objections previously stated by the Department to those changes.
  I understand and acknowledge that false statements which are intended to mislead or deceive the Commissioner, or the willful omission of any material fact with the same intent, may be punishable under such sections of the Insurance Code as may be applicable.
  WITNESS MY SIGNATURE this [__________] day of [__________], [___], at [__________].
  Signature
  [
  ]
  (Affiant)
  [
  ]
  (Printed or typed name and title)
  SUBSCRIBED AND SWORN TO before me on the date and year above written.
  [________________________________________]
  (Notary Public in and for said County and State)
  My commission expires [_______________]
2. (2) New Matters Form:
  DESCRIPTION OF NEW MATTERS FORM
1. Background Information:
1. a. Applicant's name:
2. b. Applicant's state of domicile:
3. c. Date of applicant's California Certificate of Authority:
4. d. Date of applicant's original qualification for California Variable Authority:
5. e. Date and type of applicant's last amendment to its California Variable Authority:
6. f. What variable products is the applicant currently offering in California?
7. g. Has the applicant ever been subject to a regulatory disciplinary action, at either a state or federal level, for actions arising out of its variable annuity or variable life business? If yes, identify each action:
2. What amendments to the applicant's current variable qualification are being requested in this application? (Be sure to include a new product form, new fund form, new subaccount/portfolio form and/or other material changes form for each applicable amendment).
1. a. New Product:
2. b. New Fund:
3. c. New Subaccount/Portfolio:
4. d. Other Material Changes:
3. Has the applicant included an original certificate of compliance?
4. Please identify the type(s) of investments presented in this application (for example):
1. a. Mutual Fund (2534.42 (b)(1))
2. b. ERISA or Other Plan (2534.42.(b)(2))
3. c. California Insurance Code Section 10506.3 Product (2534.42(b)(3))
4. d. Issued to a trust under California Insurance Code Section 10541 (2534.42(b)(4)
5. e. Private Placement (2534.42(b)(5))?
5. If the amendments set forth in the application require a filing with the Securities and Exchange Commission, the application must include an effective prospectus and statement of additional information. Applications for amended variable qualification will not be accepted for filing until an effective prospectus has been submitted.
6. If the amendments set forth in the application do not require a filing with the Securities and Exchange Commission, the application must include a private placement memorandum or comparable disclosure documentation available to purchasers of the product(s). Applications for amended variable qualification will not be accepted for filing until disclosure documents have been submitted
1. (3) New Product Form
  NEW PRODUCT FORM
1. PRODUCT NAME: What is the name of the New Product?
2. PRODUCT DESCRIPTION: Provide a brief description of the New Product.
3. POLICY FORM: Attach a specimen copy of the New Product policy form.
4. MARKETING: How will this new product be marketed? Who will be the target market for this new product? Attach copies of any advertising or marketing information that will be distributed to the applicant's marketing agents and/or sales force.
5. DISTRIBUTION: How will the New Product be distributed? Will a third party handle distribution? If yes, attach a copy of the distribution agreement.
6. ADMINISTRATION: Will the administration of this New Product be delegated to a third party? If yes, attach a copy of the administration agreement. Administration of a life or annuity product by a third party will require a third party administrator's license (California Insurance Code Section 1759).
7. SALES COMMISSION: What is the sales commission on this New Product?
8. SURRENDER CHARGE: What is the surrender charge on the New Product?
9. CONTRACT FEE: What is the annual contract fee on this New Product?
10. MORTALITY AND EXPENSE RISK CHARGES: What are the mortality and expense risk charges on this New Product?
11. PRODUCT PROSPECTUS AND STATEMENT OF ADDITIONAL INFORMATION: Does this new product require the filing of a prospectus with the Securities and Exchange Commission? If yes, attach a copy of the product prospectus and statement of additional information. (All insurers must provide an effective product prospectus and statement of additional information before an application to amend their variable qualification will be accepted for filing).
12. PLAN DOCUMENTS: If this New Product is not subject to filing with the Securities and Exchange Commission, attach a copy of the Plan Documents or other documentation which provides information about the new product.
1. (4) New Fund Form:
  NEW FUND FORM
1. FUND NAME: What is the name of the New Fund?
2. INVESTMENT ADVISOR: Who is the investment advisor for the new fund? Attach a copy of the investment advisory agreement.
3. DISTRIBUTOR: Who is the distributor (broker/dealer) for the New Fund?
4. USE OF FUND(S) BY OTHER INSURANCE COMPANIES: Has this New Fund ever been qualified for use in California as an investment for variable products? If yes, please provide the names of the insurance companies you know are qualified to offer this fund.
5. DISCIPLINARY ACTIONS: Has this New Fund, its investment advisor or its broker-dealer been subject to any disciplinary action by the Securities and Exchange Commission, the California Department of Corporations or any other State securities regulator, the National Association of Securities Dealers or any other self-regulatory organizations, or the Commodities Futures Trading Commission within the past ten years? If yes, attach a copy of each action.
6. FUND PROSPECTUS AND STATEMENT OF ADDITIONAL INFORMATION: Does this New Fund require a filing with the Securities and Exchange Commission? If yes, attach a copy of the effective fund prospectus and statement of additional information. The fund prospectus and statement of additional information must be effective before the application for amended variable qualification will be accepted for filing.
7. PLAN DOCUMENTS: If the New Fund is not subject to filing with the Securities and Exchange Commission, attach a copy of the Plan Documents or other documentation which provides information about the New Fund.
1. (5) New Subaccount Form:
  NEW SUBACCOUNT FORM
1. SUBACCOUNT NAME: What is the name of the New Subaccount?
2. INVESTMENT OBJECTIVE: What is the principal investment objective of the New Subaccount?
3. SUBACCOUNT MANAGER: Who is the Subaccount manager for the New Subaccount?
4. FEES: Are any fees charged by the New Subaccount? If yes, identify each charge.
5. DISCIPLINARY ACTIONS: Has the New Subaccount or its portfolio manager been subject to any disciplinary action by the Securities and Exchange Commission, the California Department of Corporations or any other State securities regulator, the National Association of Securities Dealers or any other self-regulatory organizations, or the Commodities Futures Trading Commission within the past ten years? If yes, attach a copy of the action.
6. PROSPECTUS AND STATEMENT OF ADDITIONAL INFORMATION: Does the New Subaccount require a filing with the Securities and Exchange Commission? If yes, attach a copy of the effective product and/or fund prospectus and statement of additional information relating to the addition of this New Subaccount. The product and/or fund prospectus must be effective before the application for amended variable qualification will be accepted for filing.
7. PLAN DOCUMENTS OR OTHER INFORMATIONAL MATERIAL: If the New Subaccount is not subject to Securities and Exchange Commission filing, attach a copy of the Plan Documents or other informational material which provides information about the subaccount/portfolio.
1. (6) Other Material Changes Form:
  OTHER MATERIAL CHANGES
1. OTHER MATERIAL CHANGES: Identify any material changes to the applicant's current variable qualification.
(Examples of material changes are as follows: 1) change of custodian; 2) change of administrator; 3) change of broker/dealer; 4) change of investment advisor; 5) change of portfolio manager; 6) change in fund or portfolio name; 7) change in fund or portfolio investment objective; 8) disciplinary action taken by the Securities and Exchange Commission, the California Department of Corporations or any other State securities regulator, the National Association of Securities Dealers or any other self-regulatory organizations, or the Commodities Futures Trading Commission against fund, investment advisor, portfolio manager or broker/dealer; 9) regulatory action against the insurer arising out of its variable annuity or variable life business; 10) amendments to: a) the Board of Directors resolutions, b) the agreement establishing the separate account, c) the variable contract, or d) registration statement or prospectus; and 11) any substantial change in management of the Separate Account).
2. PROSPECTUS AND STATEMENT OF ADDITIONAL INFORMATION: If filing with the Securities and Exchange Commission is required for any of the changes listed above, attach a copy of the effective prospectus and statement of additional information which reflects these changes.
3. PLAN DOCUMENTS: If filing with the Securities and Exchange Commission for any of the changes identified above is not required, attach a copy of the Plan Documents or other documentation which provides information about these changes.

Note: Authority cited: Section 10506(h), Insurance Code. Reference: Section 10506(h), Insurance Code.

History

1. New section filed 12-13-2006; operative 1-12-2007 (Register 2006, No. 50).