Minnesota Administrative Rules

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)
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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