(1) Each statement filed by or on behalf of a participant other than an insurer, in a proxy solicitation in an election contest, shall state:

(a) The time and circumstances under which the solicitor became a participant in the solicitation and the nature and extent of the solicitor's activities or proposed activities as a participant;

(b) Where practicable, a brief statement of the approximate amount of any material interest, direct or indirect, of the solicitor and of each of his associates in any material transactions since the beginning of the company's last fiscal year, or in any material proposed transaction, to which the company or any of its subsidiaries or affiliates was or is to be a party;

(c) Whether the solicitor or any of his associates have any arrangement or understanding with any person with respect to any future employment by the insurer or its subsidiaries or affiliates, or with respect to any future transactions to which the insurer or any of its subsidiaries or affiliates will be or may be a party, and, if so, a description of the arrangement or understanding and the names of the parties to it.

(2) Each statement filed by or on behalf of a participant other than an insurer, in a proxy solicitation in an election contest, shall be dated and signed in the following manner:

I certify that the statement filed by or on behalf of a participant other than an insurer, in a proxy solicitation in an election contest, shall be dated and signed in the following manner: ,

I certify that the statements made in this statement are true, complete, and correct, to the best of my knowledge and belief.

�

________________________�������������������������������������������������������������__________________________

����������(Date)�����������������������������������������������������������������������������������������������(Signature of participant or

��������������������������������������������������������������������������������������������������������������������authorized representative)