Ind. Admin. Code tit. 760, r. 1-12-4
Authority: IC 27-1-3-7
Affected: IC 27-2-10-1
Sec. 4. Regulations under Section 1 of the Act. Filing of Statements. Initial statements of beneficial ownership of equity securities required by Section 1 [ IC 27-2-10-1] of the Act shall be filed on Form A, attached hereto. Statements of changes in such beneficial ownership required by Section 1 [ IC 27-2-10-1] shall be filed on Form B, attached hereto. All such statements shall be prepared and filed in accordance with the requirements of the applicable form.
| STATE OF INDIANA | |
|---|---|
| INSURANCE COMMISSIONER | |
| FORM A | |
| INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES | |
| Filed pursuant to Acts 1965, Chapter 5, Section 1 (Sec. 39-3727 – Burns Indiana Statutes annotated) | |
| (Name of stock 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 instruction 5) | |
| Date of event which requires the filing of this statement. (See instruction 6) | |
| SECURITIES BENEFICIALLY OWNED | |||||
|---|---|---|---|---|---|
| TITLE OF SECURITY(See instruction 7) | NATURE OF OWNERSHIP(See instruction 8) | AMOUNT OWNEDbeneficially(See instruction 9) | |||
| REMARKS: (See instruction 10) | |||||
| Date of statement | |||||
| Signature | |||||
| 65-INS-A | |||||
| STATE OF INDIANA |
|---|
| INSURANCE COMMISSIONER |
| FORM B |
| STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES |
| Filed pursuant to Acts 1965, Chapter 5, Section 1 (Sec. 39-3727 – Burns Indiana Statutes annotated) |
| (Name of stock 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 instruction 5) |
| Statement for Calendar Month of ___________________, 19_______ |
| CHANGES DURING MONTH AND MONTH-END OWNERSHIP (See instruction 6) | |||||
| TITLE OF SECURITY(See instruction 7) | DATE OF TRANSACTION(See instruction 8) | AMOUNT BOUGHTor otherwise acquired(See instruction 9) | AMOUNT SOLD or otherwise acquired(See instruction 9) | NATURE OF OWNERSHIP(See instruction 10) | AMOUNT OWNED beneficially at end of month(See instruction 9) |
| REMARKS: (See instruction 11 &12) | |||||
| Date of statement ____________________ | |||||
| Signature | |||||
| 65-INS-B | |||||
(Department of Insurance; Reg 12,III, Sec 1-1; filed Jun 7, 1966, 9:00 am: Rules and Regs. 1967, p. 102; filed Jan 6, 1970, 8:40 am: Rules and Regs. 1971, p. 169; readopted filed Sep 14, 2001, 12:22 p.m.: 25 IR 531; readopted filed Nov 27, 2007, 4:01 p.m.: 20071226-IR-760070717RFA; readopted filed Nov 26, 2013, 3:43 p.m.: 20131225-IR-760130479RFA; readopted filed Nov 19, 2019, 9:18 a.m.: 20191218-IR-760190497RFA; readopted filed Oct 22, 2025, 3:17 p.m.: 20251119-IR-760240637RFA) NOTE: Renumbered Reg 12, II, Sec 1-1 by 1971 amendment.