Prior Notice Of A Transaction

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FORM D
PRIOR NOTICE OF A TRANSACTION
Filed with the Insurance Department of the State of NEVADA
By _________________________
Name of Registrant
On Behalf of Following Insurance Companies
Name
Address
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Date:_______________________, 20_____
Name, Title, Address and telephone number of Individual to Whom Notices and Correspondence
Concerning This Statement Should Be Addressed:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
ITEM 1.
IDENTITY OF PARTIES TO TRANSACTION
Furnish the following information for each of the parties to the transaction:
(a)
Name;
(b)
Home office address;
(c)
Principal executive office address;
(d)
The organizational structure, i.e. corporation, partnership, individual, trust, etc.;
(e)
A description of the nature of the parties' business operations;
(f)
Relationship, if any, of other parties to the transaction to the insurer filing the notice,
including any ownership or debtor/creditor interest by any other parties to the transaction in the insurer
seeking approval, or by the insurer filing the notice in the affiliated parties;
(g)
Where the transaction is with a non-affiliate, the name(s) of the affiliate(s) which will
receive, in whole or in substantial part, the proceeds of the transaction.
NDOI-411 / July 2016

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