1. a) A balance sheet and statement of income for the period intervening from the last annual statement filed with the Director and the end of the month preceding the month in which the prior notification of the dividend is submitted. Indicate the amount of all unrealized capital gains included in unassigned funds.
2. b) A brief statement as to the effect of the proposed dividend upon the insurer's surplus and the reasonableness of surplus in relation to the insurer's outstanding liabilities and the adequacy of surplus relative to the insurer's financial position.

3. c) A calculation of the insurer's risk based capital level as of the most recently filed financial statement (quarterly or annual), adjusted to show the effect of the proposed dividend or other distribution.

   Pursuant to the requirements of Code Section 131.16 (or Sections 131.6 and 131.20a, in the case of

   extraordinary dividends),

   has caused this

   notice to be duly signed on its behalf in the City of

   and State of

   on the

   day of

   , 20

   .

   Name of Requesting Insurer

   By

   Type or print

   (Name)

   (Title)

   Attest:

   (Signature of Officer)

   (Title)

   CERTIFICATION

   The undersigned deposes and says that he or she had duly executed the attached notice dated

   , 20

   , for and on behalf of

   ; that he or she

   (Name of Insurer)

   is the

   of the company and that he or she is familiar

   (Title of Officer)

   with the instrument and its contents, and that the facts set forth in that instrument are true to the best of his or her knowledge, information and belief.

   (Signature)

   (Type or print name beneath)

Item 1. Type of Dividend or Distribution.

Identify the dividend or distribution as a dividend or other distribution subject to Code Section 131.16 or as an extraordinary dividend or other extraordinary distribution as defined in Code Section 131.20a(2).

Item 2. The amount of the dividend or other distribution and the date established for payment. The proposed date must be consistent with requirements for receipt of notice by the Department, as specified in Section 655.30(a).

Item 3. A statement as to whether the dividend or other distribution is to be in cash or other property, and, if in property, a description of the property, its cost, statutory carrying value, and the fair market value of the property, together with an explanation of the basis for valuation.

Item 4. The amounts and payment dates of all dividends paid within the period of 12 consecutive months ending on the date fixed for payment of the proposed dividend for which notification is being given or approval is being sought.

Item 5. An illustration of the calculation of the extraordinary dividend limit set by Code Section 131.20a. Dividends that have been or will be paid in other than cash shall be valued for the purposes of the calculation at the greater of market or statutory carrying value of the asset.

Item 6. If the notice is filed for an extraordinary dividend pursuant to Code Section 131.20a, the following items must also be included:

(Source: Amended at 41 Ill. Reg. 7586, effective June 19, 2017)