1. (a) Notice of declaration of extraordinary dividend.
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2. (b) Identification of insurer.

   1. (1) Name of insurer: ___________________________.
   2. (2) Address of insurer: __________________________.

3. (c) Declaration of dividend.

   1. (1) Date of declaration of dividend: _______________.
   2. (2) Date of proposed payment of dividend: _______________.
   3. (3) Copy of directors resolution declaring dividend and any shareholders resolution supporting such declaration are to be attached to application or set forth in entirety.

4. (d) Effect of declaration.

   1. (1) Give the total amount of dividend in dollars when so expressed, or if declared in some other terms, the approximate dollar value thereof and identify the exact property in which the dividend is payable if not cash (include method of valuing the property other than cash). ________________________.
   2. (2) Is each share of issued and outstanding stock to be treated equally in distribution of dividend, except for differences in treatment of classes of stock? ______ Yes ______ No. If no, explain difference in treatment and basis therefor ___________________________________________________________________________________________________________________________________________________________________________________.
   3. (3) If different treatment in distribution of dividend is to be given by class of stock, explain basis for such treatment: ________________________________________________________________________________________________________________________________________________________________________________.

   4. (4) Give number of shares by class to whom proposed dividend is payable, the dividend per share of each class and total amount of dividend by class of stock:

      1. (A) class ______, number of shareholders ______, amount per share ______, total amount ______;
      2. (B) class ______, number of shareholders ______, amount per share ______, total amount ______;
      3. (C) class ______, number of shareholders ______, amount per share ______, total amount ______;
      4. (D) class ______, number of shareholders ______, amount per share ______, total amount ______;
      5. (E) class ______, number of shareholders ______, amount per share ______, total amount ______.

   5. (5) By class of stock, give total amount of each dividend declared, the amount payable per share and the date of declaration for the five calendar years preceding this notice:

      1. (A) class ______, date ______, total amount ______, amount per share ______;
      2. (B) class ______, date ______, total amount ______, amount per share ______;
      3. (C) class ______, date ______, total amount ______, amount per share ______;
      4. (D) class ______, date ______, total amount ______, amount per share ______;
      5. (E) class ______, date ______, total amount ______, amount per share ______.

   6. (6) Give the net gain or loss from operations after dividends to policyholders and federal income taxes and excluding capital gains and losses of the insurer for each of the last five calendar years as reported in the insurer's annual statement to the State Board of Insurance:

      1. (A) date ______, net gain ______, net loss ______;
      2. (B) date ______, net gain ______, net loss ______;
      3. (C) date ______, net gain ______, net loss ______;
      4. (D) date ______, net gain ______, net loss ______;
      5. (E) date ______, net gain ______, net loss ______.
5. (e) Attach hereto a copy of surplus analysis form of State Board of Insurance as of date not earlier than 90 days prior to date of delivery of this notice.
6. (f) Identify property, including bank accounts, to be used to pay dividend or to be converted to pay dividend. _______________________
7. (g) Provide a balance sheet and statement of income and expenses for the period intervening from the last annual statement and the end of the month preceding the month in which this application is submitted.
8. (h) What is the insurer's ratio of capital and surplus to written premium for 12 months as of the end of the last calendar year and the same ratio after deducting therefrom the total amount of the present declaration of dividend? Actual Ratio--Ratio after Deduction _______________________
9. (i) Has the insurer within the last year or will it in the immediate future establish restrictions that did not previously exist on the volume of its underwritings? ______ Yes ______ No. If yes, explain such limitations and the reason therefor. ____________________________________________________________________________________________________________________________________________________________________________________
10. (j) Has the insurer within the last year or will it in the immediate future establish geographical underwriting restrictions that did not previously exist? ______ Yes ______ No. If yes, explain such limitations and the reasons therefor. ____________________________________________________________________________________________________________________________________________________________________________________
11. (k) Describe the existing reinsurance program of insurer, including limits of retention thereof ____________________________________________________.
12. (l) Identify and describe any deviation of more than 10% in any value of any loans or investments held by the company (other than replacement of maturing securities with comparable securities) from that disclosed in your last annual statement. ____________________________________________________________________________________________________________________________________________________________________________________
13. (m) Does the company know of any reason (other than general business trends) that its earnings in the future will decrease? ______ Yes ______ No. If yes, identify and describe. ____________________________________________________________________________________________________________________________________________________________________________________
14. (n) Identify any investment or donation by the insurer to subsidiaries made since the last calendar year or to be made in the immediate future. ____________________________________________________________________________________________________________________________________________________________________________________
15. (o) Give a brief statement as to the effect upon the insurer's surplus and the reasonableness of remaining surplus after payment of dividend in relation to the insurer's outstanding liabilities and the adequacy of surplus relative to the insurer's financial needs. ______________________________________________________
16. (p) Signatures and certification. Signature and certification of the following form:
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Source Note:The provisions of this §7.212 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 May 5, 2002, 27 TexReg 3559.