Form N-6ei-1 Notification Of Claim Of Exemption Pursuant Page 3
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5NOTIFICATION OF CLAIM OF EXEMPTION
The undersigned life insurer hereby notifies the Securities and Exchange Commission that it has established a separate account that will
be maintained and operated in Compliance with Rule _________ under the Investment Company Act of 1940, and submits the following
information.
1. Exact name of separate account:
2. Exact name of life insurer:
3. Name of State or other jurisdiction under whose laws the life insurer was organized or created:
4. Date of organization of life insurer:
5. Date of establishment of separate account:
6. Law or statute and regulation, if any, pursuant to which the separate account was organized:
7. Name and address of each director, trustee and senior officer of the separate account.
8. Furnish the following information concerning the life insurer:
a. Address of principal business office:
b.
The name and address of each director, trustee, and senior officer.
9. Exact name of the investment adviser to the separate account.
10. Furnish the following information with respect to the investment adviser:
a.
Name of state or other jurisdiction under the laws of which the investment adviser was organized.
b.
Date of organization:
c.
Principal business address:
d.
Name and address of each director and officer:
11. Exact name of the principal underwriter for the variable life insurance contracts:
12. Furnish the following information with respect to the principal underwriter:
a. Name of state or other jurisdiction under the laws of which the principal underwriter was organized.
b. Date of organization:
c. Principal business address:
d. Name and address of each director and officer:
13. If the separate account is a unit investment trust, provide the following information with respect to the investment company in
which the assets of the separate account will be invested:
a.
Exact name:
b.
Principal business address:
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