ITEM 6. MANAGEMENT AGREEMENTS, SERVICE AGREEMENTS AND COST-SHARING ARRANGEMENTS
For management and service agreements, furnish:
(a) A brief description of the managerial responsibilities, or services to be performed;
(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. TRANSACTIONS NOT IN THE ORDINARY COURSE OF BUSINESS
Provide a brief but complete description of any transaction not in the ordinary course of business.
ITEM 8. OTHER TRANSACTIONS REPORTABLE UNDER AN ORDER
Provide a brief but complete description of any transaction reportable under an order.
ITEM 9. SIGNATURE AND CERTIFICATION
Signature and certification required as follows:
SIGNATURE
  Pursuant to the requirements of ch. Ins 40, Wis. Adm. Code,
    has caused this notice to be duly signed on its behalf in the city of     and state of     on the______day of_____________.

    (SEAL)
_________________________
      Name of Registrant

    BY________________________
(Name) (Title)

Attest:
   
(Signature of Officer)

   
(Title)

  The undersigned deposes and says that (s)he has duly executed the attached notice dated   ,___________, for and on behalf of     ; and that s(he) is the
(Name of Registrant)
    and that s(he) is authorized to execute and
(Title of Officer)
file such instrument. Deponent further says that (s)he is familiar with such instrument and the contents thereof, and that the facts therein set forth are true to the best of his/her knowledge, information and belief.
     
   
      (Signature)
     
   
      (Type or print name beneath)

Subscribed and sworn to this
_________day of_________,________
Notary Public
My commission expires
_________________
FORM E
RE-ACQUISITION NOTIFICATION FORM
REGARDING THE POTENTIAL COMPETITIVE IMPACT OF A PROPOSED MERGER OR
ACQUISITION BY A NON-DOMICILIARY INSURER DOING BUSINESS IN THIS STATE OR BY A
DOMESTIC INSURER

Filed with the Office of the Commissioner of Insurance,
State of Wisconsin

________________________________
Name of Applicant

________________________________
Name of Other Person
Involved in Merger or
Acquisition
Dated:_______________, 20____
Name, title, address and telephone number of person completing this statement:
ITEM 1. NAME AND ADDRESS
State the names and addresses of the persons who hereby provide notice of their involvement in a pending acquisition or change in corporate control.
ITEM 2. NAME AND ADDRESSES OF AFFILIATED COMPANIES
State the names and addresses of the persons affiliated with those listed in Item 1. Describe their affiliations.
ITEM 3. NATURE AND PURPOSE OF THE PROPOSED MERGER OR ACQUISITION
State the nature and purpose of the proposed merger or acquisition.
ITEM 4. NATURE OF BUSINESS