STATE OF CALIFORNIA
Dave Jones, Insurance Commissioner

DEPARTMENT OF INSURANCE
45 FREMONT STREET, 24TH FLOOR
SAN FRANCISCO, CA 94105

NOTICE TO ALL ADMITTED STOCK OR MUTUAL, FRATERNAL OR RECIPROCAL INSURERS
January 1, 2013
Subject: Information Statement

The Information Statement below covering the period from January 1, 2012 to December 31, 2012 must be completed by all insurers. The statement is due in the Office of the California Insurance Commissioner by April 1, 2013, and should be sent directly to the above address to the attention of Legal Branch, in order to establish the company's continuing qualification to hold a California Certificate of Authority.

Major changes within your Company during the past calendar year, such as those addressed in the Annual Information Statement, should have been reported to, and where necessary, prior approval obtained from the California Insurance Commissioner. If approval was not obtained, please provide that documentation with this Information Statement.

All questions must be answered. Indicate N/A if not applicable.

Please read the entire question carefully before responding. In several instances a "yes" response requires that you submit additional information/documentation.

California Certificate of Authority is continuous; no new renewal certificate will be issued. (California Insurance Code Section 701)

Very truly yours,

Pauline D'Andrea
Legal Branch
(415) 538-4154

Stock or Mutual Insurer: Stock or Mutual Insurer Annual Information Statement (.doc)

Fraternal Insurer: Fraternal Insurer Annual Statement (.doc)