Form AIS-F "Annual Information Statement (Fraternal)" - California

What Is Form AIS-F?

This is a legal form that was released by the California Department of Insurance - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2020;
  • The latest edition provided by the California Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form AIS-F by clicking the link below or browse more documents and templates provided by the California Department of Insurance.

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STATE OF CALIFORNIA – DEPARTMENT OF INSURANCE
ANNUAL INFORMATION STATEMENT (FRATERNAL)
AIS-F (Rev. 10/2021)
The answers on this statement must reflect any pertinent changes during the past calendar year. Those not
previously submitted to and approved by the California Insurance Commissioner require immediate
submission.
Answer completely and accurately.
For Period Covering January 1 - December 31, _____
1. Name of Company: ______________________________________________________________
a. Statutory Home Office Address:
________________________________ ____________
Street (No P.O. Box)
Suite
________________________________ ____________ ___________
City
State
Zip Code
Check if the state of domicile is different from California Certificate of Authority.
A checked box requires an amendment to the California Certificate of Authority. The
California form and process for redomestication can be accessed on the
Amended
Certificate of Authority
web page.
b. Mailing Address (All mailings from the Department will go to this address):
________________________________ ___________
Street or P.O. Box
Suite
________________________________ ____________ ___________
City
State
Zip Code
Check if different from last year. Date moved: ____________________
2. Has there been any change in your organization's name or address since last June 30?
Yes
No
If yes, give new name and/or address.
______________________________________________________________
Name
________________________________ ____________
Street (No P.O. Box)
Suite
________________________________ ____________ ___________
City
State
Zip Code
3. Have you amended your Articles of Incorporation since last June 30?
Yes
No
If yes, has a copy thereof, certified by the custodian of the original, been filed with this
Department and attached a filing fee of $380.00?
Yes
No
4. Have you amended your Constitution or Bylaws or other organizational and governing documents
by whatever name known during the current license period?
Yes
No
If yes, have you filed with this Department a copy of each such amendment or each such
document, as amended, certified by your secretary or corresponding officer to be a true copy of the
original and attached a filing fee of $380.00?
Yes
No
If all such amendments have not been filed, you should do so at once.
5. When was the last meeting of your supreme legislative convention held? ____________________
6. Have you obtained approval of the California Insurance Commissioner of all application,
certificate and rider forms you use or issue, or plan to issue in California?
Yes
No
If no, you must obtain such approval of each such form before it is used or issued in California or
issued to a member resident of California.
7. Has any officer, director, agent or employee of the Society for himself/herself or as partner or
agent of others, directly or indirectly: (a) borrowed any of the Society's funds, (b) become endorser
or surety for loans by the Society to others, or (c) in any manner become an obligor for monies
borrowed or loaned by the Society?
Yes
No
If yes, describe details and provide copies of the documents to this Department.
8. Has any officer, trustee, agent or employee of the Society asked, received, or consented or agreed
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STATE OF CALIFORNIA – DEPARTMENT OF INSURANCE
ANNUAL INFORMATION STATEMENT (FRATERNAL)
AIS-F (Rev. 10/2021)
The answers on this statement must reflect any pertinent changes during the past calendar year. Those not
previously submitted to and approved by the California Insurance Commissioner require immediate
submission.
Answer completely and accurately.
For Period Covering January 1 - December 31, _____
1. Name of Company: ______________________________________________________________
a. Statutory Home Office Address:
________________________________ ____________
Street (No P.O. Box)
Suite
________________________________ ____________ ___________
City
State
Zip Code
Check if the state of domicile is different from California Certificate of Authority.
A checked box requires an amendment to the California Certificate of Authority. The
California form and process for redomestication can be accessed on the
Amended
Certificate of Authority
web page.
b. Mailing Address (All mailings from the Department will go to this address):
________________________________ ___________
Street or P.O. Box
Suite
________________________________ ____________ ___________
City
State
Zip Code
Check if different from last year. Date moved: ____________________
2. Has there been any change in your organization's name or address since last June 30?
Yes
No
If yes, give new name and/or address.
______________________________________________________________
Name
________________________________ ____________
Street (No P.O. Box)
Suite
________________________________ ____________ ___________
City
State
Zip Code
3. Have you amended your Articles of Incorporation since last June 30?
Yes
No
If yes, has a copy thereof, certified by the custodian of the original, been filed with this
Department and attached a filing fee of $380.00?
Yes
No
4. Have you amended your Constitution or Bylaws or other organizational and governing documents
by whatever name known during the current license period?
Yes
No
If yes, have you filed with this Department a copy of each such amendment or each such
document, as amended, certified by your secretary or corresponding officer to be a true copy of the
original and attached a filing fee of $380.00?
Yes
No
If all such amendments have not been filed, you should do so at once.
5. When was the last meeting of your supreme legislative convention held? ____________________
6. Have you obtained approval of the California Insurance Commissioner of all application,
certificate and rider forms you use or issue, or plan to issue in California?
Yes
No
If no, you must obtain such approval of each such form before it is used or issued in California or
issued to a member resident of California.
7. Has any officer, director, agent or employee of the Society for himself/herself or as partner or
agent of others, directly or indirectly: (a) borrowed any of the Society's funds, (b) become endorser
or surety for loans by the Society to others, or (c) in any manner become an obligor for monies
borrowed or loaned by the Society?
Yes
No
If yes, describe details and provide copies of the documents to this Department.
8. Has any officer, trustee, agent or employee of the Society asked, received, or consented or agreed
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STATE OF CALIFORNIA – DEPARTMENT OF INSURANCE
ANNUAL INFORMATION STATEMENT (FRATERNAL)
AIS-F (Rev. 10/2021)
to receive anything of value for procuring or endeavoring to procure a loan to any person from the
trust funds of, or funds belonging to, the Society?
Yes
No
If yes, describe details and provide copies of the documents to this Department.
9. Without having first obtained the written consent of the California Insurance Commissioner, has
any person having authority in the management of the Society's funds or any officer, director or
trustee of the Society: (a) received any money or valuable thing for negotiating, procuring,
recommending or aiding in any loan from the Society or any purchase by or sale to the Society of
any real or personal (tangible or intangible) property, (b) had any pecuniary interest as principal,
coprincipal, agent, attorney or beneficiary in any such loan, purchase or sale, or (c) directly or
indirectly purchased or been pecuniarily interested in the purchase of any of the assets of the
Society? As used herein, the word "property" also includes leases and management, investment
and/or administrative service agreements.
Yes
No
If yes, explain in detail and attach all contractual arrangements.
If the California Insurance Commissioner's prior written consent was obtained to the transaction
and/or contractual arrangement, have there been, in the interim, any changes, modifications or
amendments in either the terms or compensation without having first obtained the Commissioner's
written consent to the changes, modifications or amendments?
Yes
No
If yes, explain the changes noting any prior contact made with the Department with respect thereto
and attach copies thereof.
10. Without having first obtained the written consent of the California Insurance Commissioner, has
the Society entered, or does it have any plans to enter, into any transaction the effect of which is:
(a) to merge or consolidate with or into a general mutual or stock insurer, whether or not admitted
to California, or (b) to be converted into a general mutual insurer?
Yes
No
If yes, explain in detail and attach all of the contractual arrangements.
11. Without having first obtained the written consent of the California Insurance Commissioner, has
the Society transferred, or attempted to transfer its entire property or business to any other person,
or has the Society entered into any transaction the effect of which is to reinsure substantially all of
its insurance business with any other person, whether or not admitted to California? As used
herein, the word "substantially" means 75% or more. The word "person" includes all legal entities.
Yes
No
If yes, explain in detail and attach all contractual arrangements.
12. Has the Society reinsured or assumed substantially all of the insurance business in force of any
other insurer or society, whether or not admitted to California? As used herein, the word
"substantially" means 75% or more.
Yes
No
If so, explain details noting name of cedent and any prior contact with the Department; attach
copies of all contractual arrangements and, if applicable, assumption certificates.
13. Has the Society ceded less than 75% of its insurance business in force to a non-admitted insurer or
society or to one which has not been approved for such purpose by the California Insurance
Commissioner?
Yes
No
If yes, explain in detail and attach all contractual arrangements.
I hereby declare under the penalty of perjury under the laws of the State of California that the foregoing
answers are true and correct.
By:
______________________________
Signature
(Corporate seal)
Name: ______________________________
Title:
______________________________
Date:
______________________________
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STATE OF CALIFORNIA – DEPARTMENT OF INSURANCE
ANNUAL INFORMATION STATEMENT (FRATERNAL)
AIS-F (Rev. 10/2021)
Name of person who filled out this Statement:
______________________________
(Print)
______________________________
(Title)
______________________________
(Date)
Enter toll free number, otherwise collect call must be accepted.
Telephone Number: ____________________
Email: ______________________________
Return to:
State of California
Department of Insurance
Corporate Affairs Bureau
1901 Harrison Street, 6th Floor
Oakland, CA 94612
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