1. (a) Disclaimer of control or affiliation filed with the Texas Department of Insurance by _________________(name of applicant).
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2. (b) The applicant does not directly or indirectly exercise or have a right to exercise control, within the meaning as defined by the Insurance Holding Company System Regulatory Act, the Insurance Code, Article 21.49-1, and regulations issued thereunder, over: ____________________.
3. (c) Applicant is directly or indirectly controlled by or under common control with the previously named insurer. ____Yes ____No

4. (d) Insofar as is known to applicant, all material relationships between the undersigned and said insurer are:

   1. (1) the total number of authorized, issued, and outstanding voting securities or rights of said insurer (listed by class) is: __________________.

   2. (2) Of such shares or voting rights, the applicant owns, controls, or holds a discretionary right to vote (by proxy or otherwise) the following shares or voting rights of the insurer:

      1. (A) class of stock (if applicable) ______, number of shares or voting rights ______, approximate percent of total issued and outstanding shares or voting rights ______;
      2. (B) class of stock (if applicable) ______, number of shares or voting rights ______, approximate percent of total issued and outstanding shares or voting rights ______;
      3. (C) class of stock (if applicable) ______, number of shares or voting rights ______, approximate percent of total issued and outstanding shares or voting rights ______;
      4. (D) class of stock (if applicable) ______, number of shares or voting rights ______, approximate percent of total issued and outstanding shares or voting rights ______;
      5. (E) class of stock (if applicable) ______, number of shares or voting rights ______, approximate percent of total issued and outstanding shares or voting rights ______.
   3. (3) If the answer to the preceding inquiry would have varied more than 20% if asked as of any date within the preceding 14 months, give the maximum number of shares of each class of voting security or voting rights the applicant owned, controlled, or held a discretionary right to vote (by proxy or otherwise) at any time during the preceding 14 months ____________________.

   4. (4) The total number of issued and outstanding voting securities or voting rights held by persons who control said insurer is:

      1. (A) person ______, class ______, number of shares or voting rights ______;
      2. (B) person ______, class ______, number of shares or voting rights ______;
      3. (C) person ______, class ______, number of shares or voting rights ______;
      4. (D) person ______, class ______, number of shares or voting rights ______;
      5. (E) person ______, class ______, number of shares or voting rights ______.

   5. (5) Of such number of shares or voting rights mentioned in the preceding inquiry, the applicant and its affiliates (if any) own, control, or exercise a discretionary right to vote (by proxy or otherwise) the following classes and number of voting securities or voting rights:

      1. (A) class ______, number of shares or voting rights ______;
      2. (B) class ______, number of shares or voting rights ______;
      3. (C) class ______, number of shares or voting rights ______;
      4. (D) class ______, number of shares or voting rights ______;
      5. (E) class ______, number of shares or voting rights ______.
   6. (6) Other: ____________________.
5. (e) The basis for disclaiming the applicant's present or immediately future affiliation to said insurer is: ____________________.
6. (f) Signatures and certification. Signatures and certification of the following form:
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Source Note:The provisions of this §7.211 adopted to be effective January 1, 1976; amended to be effective November 30, 1984, 9 TexReg 5926; amended to be effective April 13, 1992, 17 TexReg 2273; amended to be effective July 14, 1994, 19 TexReg 5098; amended to be effective May 5, 2002, 27 TexReg 3559.