Section 653.ILLUSTRATION A Form CX

INSTRUCTIONS FOR COMPLETION

FORM CX

PRE-ACQUISITION NOTIFICATION

Filed with the Insurance Department of the State of Illinois.

(Name of Registrant)

On Behalf of the Following Insurance Companies

Date:

, 20

Name, Title and Address of Officer to Whom Notices and Correspondence Concerning this Statement Should be Addressed: ___________________________________________________

Item 1. Parties.

Identify all "involved insurers", "acquired persons" or "acquired insurers" subject to Section 131.12a of the Illinois Insurance Code.

Item 2. Method and Date of Acquisition.

Describe the transactions that will occur and may directly or indirectly change the control, as defined in Code Section 131.1(b), of an insurer authorized to do business in this State. Identify the effective date for the transactions.

Item 3. Market Shares.

Identify the rank and percent of the market share for each insurer or group of insurers as defined by Code Section 131.12a by line of insurance. The lines of insurance include Illinois business reported on the Direct Business In The State Of Illinois page of the Life, Accident and Health Annual Statement blank and the Exhibit of Premiums and Losses (Statutory Page 14) page of the Property and Casualty Annual Statement blank as filed with the Director for the preceding year as required by Code Section 136.

Item 4. Expert Opinion (Optional).

Include statement by economist regarding competitive impact of acquisition. The statement shall also include the qualifications of that economist.

Item 5. Filing Fees.

Pursuant to Code Section 408, the Director shall collect a fee for the filing of a statement of acquisition of a foreign or alien insurance company. This filing shall not be deemed complete until the Director has received the appropriate filing fee required by Section 408.

Item 6. This Form is not to be used as a blank form to be filled in, but only as a guide in the preparation of the statement.

Item 7. Incorporation by Reference

a) Materials required by any item of this statement may be incorporated by reference in answer or partial answer to any other item.

b) Information contained in any financial statement, annual report, proxy statement, statement filed with a governmental authority, or any other document may be incorporated by reference in answer or partial answer to any item, provided the document or paper is filed as an exhibit to the statement. Excerpts of documents may be filed as exhibits if the documents are extensive. Documents currently on file with the Director that were filed within the prior three years need not be attached as exhibits. References to information contained in exhibits or in documents already on file shall clearly identify the material and shall specifically indicate that the material is to be incorporated by reference in answer to the item. Material shall not be incorporated by reference in any case in which the incorporation would render the statement incomplete, unclear or confusing.

c) When an item requires a summary or outline of the provisions of any document, only a brief statement shall be made as to the pertinent provisions of the document. In addition to the statement, the summary or outline may incorporate by reference particular parts of any exhibit or document currently on file with the Director that was filed within three years and may be qualified in its entirety by the reference. In any case in which two or more documents required to be filed as exhibits are substantially identical in all material respects except as to the parties, the dates of execution, or other details, a copy of only one of the documents need be filed, with a schedule identifying the omitted documents and setting forth the material details in which the documents differ from the documents a copy of which is filed.

Affidavit of Registrant.

State of		)
		)
County of		)

(Company officer)

being duly sworn, deposes and says:

That he or she is the	(Title)	of the	(Name of the Company)		, a corporation organized
and existing under and by virtue of the laws of the State of				(State)		; and on whose
behalf makes this Affidavit.

Deponent says that he or she is familiar with Pre-Acquisition Notification and its contents, and that the facts set forth are true to the best of his or her knowledge, information and belief.

____________________________________

(Signature)

(Type or Print Name Beneath)

(Source: Amended at 41 Ill. Reg. 7578, effective June 19, 2017)