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2715.6401 FORM A: STATEMENT OF OWNERSHIP.

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF EQUITY SECURITIES
(File with Respect to Domestic Stock Insurer
Pursuant to Minnesota Statutes, Section 60A.22)
Name of Insurer:
Address:
Name of Person Whose Ownership is Reported:
Address:
Relationship of Such Person to Insurer (See Part 2715.6402, Subpart 4):
Date Indicated Relationship Occurred:

EQUITY SECURITIES BENEFICIALLY OWNED

Title of Security
(See Part 2715.6402, Subpart 5)
Nature of Ownership
(See Part 2715.6402, Subpart 6)
Amount Beneficially Owned
(See Part 2715.6402, Subpart 7)
.
.
.
.
.
.
.
.

Remarks (See Part 2715.6402, Subpart 8):

I affirm under penalty of perjury that the foregoing is full, true, and correct.
Date of Statement:
Where Made: _
(Signature)

Statutory Authority:

MS s 60A.22

Published Electronically:

September 14, 2007

Official Publication of the State of Minnesota
Revisor of Statutes