INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES

(To be filed with the department of insurance pursuant to Section 59A-36-2 NMSA 1978.)

________________________________________

(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 13 NMAC 3.2.11) [now 13.3.2.11 NMAC]

________________________________________

Date of event which requires the filing of this statement. (See 13 NMAC 3.2.12) [now 13.3.2.12 NMAC]

SECURITIES BENEFICIALLY OWNED

TITLE OF SECURITY (See 13 nmac 3.2.13 [now 13.3.2.13 NMAC] NATURE OF OWNERSHIP (See 13 nmac 3.2.14) [now 13.3.2.14 NMAC] AMOUNT OWNED BENEFICIALLY (See 13 NMAC 3.2.15) [now 13.3.2.15 NMAC]

TITLE OF SECURITY

(See 13 nmac 3.2.13

[now 13.3.2.13 NMAC]

NATURE OF OWNERSHIP

(See 13 nmac 3.2.14)

[now 13.3.2.14 NMAC]

AMOUNT OWNED BENEFICIALLY

(See 13 NMAC 3.2.15)

[now 13.3.2.15 NMAC]

REMARKS: (see 13 NMAC 3.2.16) [now 13.3.2.16 NMAC]

Date of statement: ________________________________________

I affirm under penalty or perjury that the foregoing is full, true and correct.

________________________________________

Signature

_______________________________________

(Signature guaranteed)

[7/1/97; Recompiled 11/30/01]

HISTORY OF 13.3.2 NMAC:

Pre-NMAC History: The material in this rule was originally filed with the State Records Center as:

ID 67-1, Sections 4-2-1 through 4-2-12, New Mexico Official Administrative Rules and Regulations Code, on 12/1/67.

History of Repealed Material: [RESERVED]