Prior Notice Of A Transaction (Page 4 of 5) in pdf

Prior Notice Of A Transaction Page 4

(b)

A brief description of the agreement, including a statement of its duration, together with

brief descriptions of the basis for compensation and the terms under which payment or compensation is

to be made.

For cost-sharing arrangements, furnish:

(a)

A brief description of the purpose of the agreement;

(b)

A description of the period of time during which the agreement is to be in effect;

(c)

A brief description of each party's expenses or costs covered by the agreement;

(d)

A brief description of the accounting basis to be used in calculating each party's costs

under the agreement.

(e)

A brief statement as to the effect of the transaction upon the insurer’s policyholder

surplus;

(f)

A statement regarding the cost allocation methods that specifies whether proposed

charges are based on “cost or market.” If market based, rationale for using market instead of cost,

including justification for the company’s determination that amounts are fair and reasonable; and

(g)

A statement regarding compliance with the NAIC Accounting Practices and Procedure

Manual regarding expense allocation.

ITEM 7.

SIGNATURE AND CERTIFICATION

Signature and certification required as follows

Pursuant to the requirements of Chapter 692C, of the Nevada Revised Statutes, Section 363 and

the Nevada Administrative Code, Section 040, Registrant has caused this application to be duly signed

on its behalf of the City of

and State of

on the

day

, 20

(SEAL)

_____________________________

Name of Applicant

BY _____________________________

(Name) (Title)

Attest:

__________________________________

(Signature of Officer)

__________________________________

(Title)

NDOI-411 / July 2016

Prior Notice Of A Transaction Page 4

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