Form N-6ei-1 Notification Of Claim Of Exemption Pursuant Page 4
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5c.
Name and address of the Investment Adviser:
d. Name and address of the Principal Underwriter:
14. Exact name and address of Independent Public Accounting for the separate account.
15. Exact name and address of the Custodian or the bank or other company in whose safekeeping the assets of the separate account
will be held:
16. Exact name of variable life insurance contract(s) to be funded by this separate account:
17. State the investment objectives of the separate account.
18. State the fundamental investment policies and techniques of the separate account.
19. List the types and amounts of any charges to be made on a periodic basis against the assets of the separate account.
20. Furnish the information required by the following table with reference to: (a) every company owning 5% or more of the voting
securities of the life insurer, (b) every company owning 5% or more of the voting securities of which are owned directly by the
life insurer, and (c) every company owning 5% or more of the voting securities which are owned by any company owning 5%
or more of the voting securities of which are owned by the life insurer.
_______________________________________________________________________________________________________
State of
Foreign
Percentage
country under
voting
Name of
Date of
Form
laws of which
Principal
securities
Company
organization
organization
organized
business
owned
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21. Annex the latest regular periodic report filed with the superintend of insurance of the life insurers domicile and, if available,
submit in the form of an attached exhibit a copy of the life insurers last regular periodic report to its security holders or
policyholders.
Indent to show degree of remoteness from the insurer, for example –
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Life Insurer
Company A (5% or more of voting securities of which held by life insurer)
Company B (5% or more of voting securities held by Company A)
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