3 AAC 21.186. Pre-notification of proposed merger or acquisition of insurer; Form E

(a) An insurer required to file notice under AS 21.22.065 of a proposed merger or acquisition resulting in a change of control of an insurer authorized to do business in this state shall furnish the required pre-acquisition notification information on Form E, made a part of this section in substantially the following form:

FORM E

PRE-NOTIFICATION FORM

REGARDING THE POTENTIAL COMPETITIVE IMPACT

OF A PROPOSED MERGER OR ACQUISITION BY A

NON-DOMICILIARY INSURER DOING BUSINESS IN THIS

STATE OR BY A DOMESTIC INSURER

______________________________________________________________________________

(Name of Company Merging or Acquiring/Applicant)

______________________________________________________________________________

(Name of Other Insurer(s) Involved in Merger or to be Acquired)

Filed with the Division/Department of Insurance of the State of ______________ Dated: _____________, 20____ Name, Title, Address, and Telephone Number of Individual Completing This Statement:

____________________________________________

ITEM 1. NAME AND ADDRESS State the name and address for the company(ies) identified above who are providing notice of their involvement in a pending acquisition or change in corporate control. ITEM 2. NAME AND ADDRESS OF AFFILIATED COMPANY State the name and address of the company(ies) affiliated with those listed in Item 1. Describe the affiliation(s). "Affiliated" has the meaning given in AS 21.22.200 . ITEM 3. NATURE AND PURPOSE OF THE PROPOSED MERGER OR ACQUISITION State the nature and purpose of the proposed merger or acquisition. ITEM 4. NATURE OF BUSINESS State the nature of the business performed by each of the companies identified in response to Items 1 and 2. ITEM 5. MARKET AND MARKET SHARE State specifically what market and market share in each relevant insurance market the companies identified in Item 1 and Item 2 currently experience in this state. Provide historical market and market share data for each company identified in Item 1 and Item 2 for the past five years and identify the source of the data. "Insurance market" has the meaning given in AS 21.22.200 . Furnish the data and calculations necessary for the director to make a determination under AS 21.22.065 (d). Furnish calculations, discussion, or other information that would constitute "other substantial evidence" under AS 21.22.065 (f) or would provide information supportive of AS 21.22.065 (g). Furnish other information pertinent to the approval or pre-approval sought. If a Form A, an application for certificate of authority, or another filing for the company or affiliate of the company is pending before the director of insurance of the State of Alaska, identify and describe the associated filing. Note: The Division of Insurance of the State of Alaska may additionally choose to make additional calculations under AS 21.22.065 using the division's own data or data provided by the National Association of Insurance Commissioners. ITEM 6. EXEMPTION FROM AS 21.22.065 If a company is claiming an exemption from the requirements of AS 21.22.065 under the provisions of AS 21.22.065 (j)(3), (j)(5), or (j)(7), furnish the relevant data, calculations, discussion, or other information necessary for the director to determine the appropriateness of the exemption. If a company is claiming an exemption under the provisions of AS 21.22.065 (j)(5)(A), a letter of pre-notification of acquisition may be submitted in lieu of a completed Form E. ITEM 7. SIGNATURE AND CERTIFICATION Signature and certification are required as follows:

SIGNATURE

Under the requirements of AS 21.22.065 , ________________________ has caused this notice to be signed on its behalf in the City or Community of ______________ and State of ____________ on the ____________ day of ____________, 20 ____. (SEAL) __________________________________________________________ (Name of Applicant) BY _______________________________________________________ (Name) (Title) Attest: ________________________ (Signature of Officer) ________________________ (Title)

CERTIFICATION

The undersigned deposes and says that (s)he has duly executed the attached notice dated _____________, 20 ____, for and on behalf of ________________________ (Name of Applicant); that (s)he is the ________________________ (Title of Officer) of the company; and that (s)he is authorized to execute and file the instrument. Deponent further says that (s)he is familiar with the instrument and the contents of it and that the facts stated in it are true to the best of his/her knowledge, information, and belief. (Signature) _____________________________________________________________ (Type or print name below) ____________________________________________________________

History: Eff. 1/12/95, Register 133

Authority: AS 21.06.090

AS 21.22.065

AS 21.22.130

AS 21.22.200

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