Section 760IAC1-12-4. Beneficial ownership statements; forms

   Regulations under Section 1 of the Act. Filing of Statements. Initial statements of beneficial ownership of equity securities required by Section 1 [IC 27-2-10-1] of the Act shall be filed on Form A, attached hereto. Statements of changes in such beneficial ownership required by Section 1 [IC 27-2-10-1] shall be filed on Form B, attached hereto. All such statements shall be prepared and filed in accordance with the requirements of the applicable form.

STATE OF INDIANA
INSURANCE COMMISSIONER
FORM A
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
Filed pursuant to Acts 1965, Chapter 5, Section 1 (Sec. 39-3727 ─ Burns Indiana Statutes annotated)
(Name of stock insurance company)
(Name of person whose ownership is reported)
(Business address of such person; street, city, state, zip code)
Relationship of such person to company named above. (See instruction 5)
Date of event which requires the filing of this statement. (See instruction 6)
SECURITIES BENEFICIALLY OWNED
TITLE OF SECURITY (See instruction 7)		NATURE OF OWNERSHIP (See instruction 8)		AMOUNT OWNED beneficially (See instruction 9)
REMARKS: (See instruction 10)
Date of statement
				Signature
65-INS-A

STATE OF INDIANA
INSURANCE COMMISSIONER
FORM B
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
Filed pursuant to Acts 1965, Chapter 5, Section 1 (Sec. 39-3727 ─ Burns Indiana Statutes annotated)
(Name of stock insurance company)
(Name of person whose ownership is reported)
(Business address of such person; street, city, state, zip code)
Relationship of such person to company named above. (See instruction 5)
Statement for Calendar Month of ___________________, 19_______
CHANGES DURING MONTH AND MONTH-END OWNERSHIP (See instruction 6)
TITLE OF SECURITY (See instruction 7)	DATE OF TRANSACTION (See instruction 8)	AMOUNT BOUGHT or otherwise acquired (See instruction 9)	AMOUNT SOLD or otherwise acquired (See instruction 9)	NATURE OF OWNERSHIP (See instruction 10)	AMOUNT OWNED beneficially at end of month (See instruction 9)
REMARKS: (See instruction 11 &12)
Date of statement
				Signature
65-INS-B

(Department of Insurance; Reg 12,III, Sec 1-1; filed Jun 7, 1966, 9:00 am: Rules and Regs. 1967, p. 102; filed Jan 6, 1970, 8:40 am: Rules and Regs. 1971, p. 169; readopted filed Sep 14, 2001, 12:22 p.m.: 25 IR 531; readopted filed Nov 27, 2007, 4:01 p.m.: 20071226-IR-760070717RFA; readopted filed Nov 26, 2013, 3:43 p.m.: 20131225-IR-760130479RFA) NOTE: Renumbered Reg 12, II, Sec 1-1 by 1971 amendment.