1. (a) Statement regarding the exemption from approval of the acquisition of control of a domestic insurer.
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2. (b) Insurer and method of acquisition. Provide a description of how additional control is being acquired.

3. (c) Background of the applicant.

   1. (1) Furnish a chart or listing clearly identifying the interrelationships between the applicant and all affiliates of the applicant. Indicate in such chart or listing the percentage of voting securities of each such person which is controlled by the applicant or by any other such person. If control of any person is maintained other than by the ownership or control of voting securities, indicate the basis of such control. As to each person specified in such chart or listing indicate the type of organization (e.g., corporation, trust, partnership) and the state or other jurisdiction of domicile. If court proceedings looking toward a reorganization or liquidation are pending with respect to any such person, indicate which person, and set forth the title of the court, the nature of the proceedings, and the date when commenced.
   2. (2) Fully describe any business which the applicant and any of its affiliates intend to commence.

4. (d) Nature, source, and amount of funds or other consideration.

   1. (1) Describe the nature, source, and amount of funds or other consideration used or to be used in effecting further acquisition of control. If any part of the same is represented or is to be represented by funds or other consideration borrowed or otherwise obtained for the purpose of acquiring, holding, or trading securities, furnish a description of the transaction, the names of the parties thereto, the nature and existence of all relationships, if any, in addition to the arrangements concerning the consideration borrowed between the borrower and the lender, the amounts borrowed, or to be borrowed, and copies of all agreements, promissory notes, and security arrangements relating thereto and to such other relationships.
   2. (2) If the consideration is to consist in whole or in part of the insurance business and assets of the insurer or of a person controlled by the insurer, state the value thereof and how such value was arrived at.

5. (e) Future plans for insurer.

   1. (1) Describe any plans or proposals which the applicant may have or may contemplate making to cause the insurer to pay dividends or make other distributions, to liquidate such insurer, to sell any of its assets, to merge or consolidate it with any person or persons, to make any other material change in its business operations or corporate structure or management, or to cause the insurer to enter into material agreements, arrangements, or transactions of any kind with any party, and describe any financial or employment guarantees given to present and contemplated management.
   2. (2) Provide a business plan which describes applicant's operational plans for the domestic insurer covering the succeeding 24 months, including, but not limited to, change of location, change of name, increase in capital and/or surplus, type business to be written, and anticipated premium volume. For the domestic insurer, provide the full name of any new employee or officer to be employed as a result of the further acquisition of control and provide biographical information in the form specified in §7.210(e) of this title (relating to Form B).
6. (f) Ownership of and voting securities to be acquired. State the amount of each class of any voting security of the insurer which is legally, directly, indirectly, or beneficially owned or of which the acquiring party or any of its affiliates has a right to acquire legal, direct, indirect, or beneficial ownership. State the number of shares of the insurer's voting securities and the amount or number of shares convertible into voting securities which the applicant and its affiliates plan to acquire separate and apart from the voting securities subject to this exemption statement, and the terms of the offer, request, invitation, agreement, or acquisition.
7. (g) Agreements with broker-dealers. Provide a copy of any written, or a confirmed description of any oral, agreement, arrangement, or understanding made with any broker-dealer as to the solicitation of voting securities of the insurer for tender, and the amount of any fees, commissions, or other compensation to be paid to broker-dealers with regard thereto.

8. (h) Financial statements and exhibits.

   1. (1) Financial statements and exhibits shall be attached to this statement as an appendix, but list under this subsection the financial statements and exhibits so attached.
   2. (2) The financial statements shall include the annual financial statements of the persons identified in subsection (c)(1) of this section for the preceding fiscal year, and similar unaudited financial information as of a date not earlier than 120 days prior to the filing of the statement, accompanied by affidavit or certification of the chief financial officer of the applicant that such unaudited financial statement is true and correct, as of its date, and that there has been no material change in financial condition, as defined by the Act, §3, from the date of the financial statement to the date of the affidavit or certification. Such statements may be prepared on either an individual basis, or, unless the commissioner otherwise requires, on a consolidated basis if such consolidated statements are prepared in the usual course of business. Unless exempted by the commissioner, the annual financial statement of the applicant shall be made in accordance with generally accepted auditing standards and accompanied by the certificate of an independent certified public accountant to the effect that such statement presents fairly the financial position of the applicant and the results of its operations for the year then ended, in conformity with generally accepted accounting principles or with requirements of insurance or other accounting principles prescribed or permitted under law. If such certificate is not available, then such financial statement shall be sworn to by the applicant as correctly reflecting its financial condition, and in such case, the commissioner of insurance at the commissioner's discretion may require such financial statement to be certified by an independent public accountant. If the applicant is an insurer which is actively engaged in the business of insurance and licensed to do business in this state, it may provide financial statements which conform to the annual statement of the insurer filed with the insurance department of the insurer's domiciliary state and which are in accordance with the requirements of insurance or other accounting principles prescribed or permitted under the law and regulations of the domiciliary state. If the applicant is an individual person, such person shall provide for the preceding fiscal year a reviewed financial statement accompanied by the certificate of an independent public accountant that he is not aware of any material modifications that should be made to the accompanying financial statement in order for it to be in conformity with generally accepted accounting principles and a balance sheet as of a date not earlier than 120 days prior to the filing of the statement accompanied by affidavit or certification that the balance sheet is true and correct as of its date. Any financial information required by this subsection may be waived by the commissioner if such information is not deemed material.
   3. (3) File as exhibits copies of all tender offers for, requests or invitations for, tenders of, exchange offers for, and agreements to acquire or exchange any voting securities of the insurer and (if distributed) of additional soliciting material relating thereto; and proposed employment, consultation, advisory, or management contracts concerning the insurer; budget projections of the domestic insurer and the applicant for a period equal to the greater of two years or the succeeding length of time of debt service required by applicant in its acquisition of control; and any additional document or papers required by regulation.
9. (i) Signature and certification. Signature and certification of the following form:
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Source Note:The provisions of this §7.213 adopted to be effective April 29, 1988, 13 TexReg 1761; 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.