SEC 1130 Form N-6E1-1

UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

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Form N-6EI-1
[As last amended in Release No. IC-14234, November 14, 1984, 49 F.R. 47208]

FORM N-6EI-1
Notification of Claim of Exemption Pursuant to Rule 6e-2 or 6e-3(T) Under
The Investment Company Act of 1940

__________________________________________________________________________________________________
Exact Name of Separate Account

__________________________________________________________________________________________________
Exact Name of Life Insurance Company which Established and MainWDLQV the Separate Account (“Life Insurer”)

SEC1130 (3-03)

Persons who respond to the collection of information contained in this
form are not required to respond unless the form displays a currently valid
OMB control number.

INSTRUCTIONS FOR FORM N-6EI-1
Read instructions carefully before preparing this Notification. It will not be deemed acceptable unless it is prepared, executed and filed
substantially in accordance with these instructions.
1. Rule as to use of form:
This form shall be used as the notification of claim of exemption filed with the Commission under either Rule 6e-2 or 6e-3(T) under the
Investment Company Act of 1940.
2. Preparation of form of Notification:
(a) Every item is to be answered fully and accurately. If an item is not applicable indicate that fact by giving the answer “not
applicable.”
(b) Every item is to be answered as of the date the form is prepared, unless the context clearly indicated the contrary.
(c) All answers are to be typewritten or printed. The reply should be centered on the page so that a margin will appear on
both sides. If the space provided for an answer is insufficient, separate sheets of the same size as the form shall be used
and attached to the form as exhibits. Each such sheet shall be identified at the top as follows: “Either No. ___________,
referring to Item _________ of the Form of Notification of Claim of Exemption.” Where such sheets are used, reference
thereto shall be made under the appropriate item of the form by the words “See Exhibit No. __________________.”
(d) Names shall be given in full, initials or abbreviations will not suffice.
(e) Signature. An original and five copies of each Notification of Claim of Exemption shall be filed. The original Notification
shall be signed by the Chairman of the Board of Directors of the separate account claiming exemption, and by a senior
officer or trustee of the life insurer.
The five copies of the Notification may have facsimile or typed signatures.
(f) Filing. The Notification and all inquiries and communications with respect thereto shall be forwarded to the Securities and
Exchange Commission, Washington, D.C. 20549.
(g) Fee. There is no fee charged for filing the Notification.
SEC’s Collection of Information
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently
valid control number. Section 8(a) of the Investment Company Act of 1940 generally requires investment companies to register with
the Commission by filing a notification of registration. Paragraph (b)(3)(i) of Rule 6e-2 allows separate accounts qualifying for the
exemptions under the rule to file a notification of a claim of exemption on Form N-6EI-1 in lieu of the notification of registration required
by Section 8(a). The form will permit the Commission and the staff to monitor the number and types of separate accounts operating
pursuant to the exemptions provided by the rule.

2

NOTIFICATION OF CLAIM OF EXEMPTION
The undersigned life insurer hereby notifies the Securities and Exchange Commission that it has established a separate account that will
be maintained and operated in Compliance with Rule _________ under the Investment Company Act of 1940, and submits the following
information.
1. Exact name of separate account:
2. Exact name of life insurer:
3. Name of State or other jurisdiction under whose laws the life insurer was organized or created:
4. Date of organization of life insurer:
5. Date of establishment of separate account:
6. Law or statute and regulation, if any, pursuant to which the separate account was organized:
7. Name and address of each director, trustee and senior officer of the separate account.
8. Furnish the following information concerning the life insurer:
a. Address of principal business office:
b. The name and address of each director, trustee, and senior officer.
9. Exact name of the investment adviser to the separate account.
10. Furnish the following information with respect to the investment adviser:
a. Name of state or other jurisdiction under the laws of which the investment adviser was organized.
b. Date of organization:
c. Principal business address:
d.

Name and address of each director and officer:

11. Exact name of the principal underwriter for the variable life insurance contracts:
12. Furnish the following information with respect to the principal underwriter:
a. Name of state or other jurisdiction under the laws of which the principal underwriter was organized.
b. Date of organization:
c. Principal business address:
d. Name and address of each director and officer:
13. If the separate account is a unit investment trust, provide the following information with respect to the investment company in
which the assets of the separate account will be invested:
a. Exact name:
b. Principal business address:



c. Name and address of the Investment Adviser:
d. Name and address of the Principal Underwriter:
14. Exact name and address of Independent Public Accounting for the separate account.
15. Exact name and address of the Custodian or the bank or other company in whose safekeeping the assets of the separate account
will be held:
16. Exact name of variable life insurance contract(s) to be funded by this separate account:
17. State the investment objectives of the separate account.
18. State the fundamental investment policies and techniques of the separate account.
19. List the types and amounts of any charges to be made on a periodic basis against the assets of the separate account.
20. Furnish the information required by the following table with reference to: (a) every company owning 5% or more of the voting
securities of the life insurer, (b) every company owning 5% or more of the voting securities of which are owned directly by the
life insurer, and (c) every company owning 5% or more of the voting securities which are owned by any company owning 5%
or more of the voting securities of which are owned by the life insurer.
_______________________________________________________________________________________________________

State of

Name of
Date of
Form
Company1
organization
organization

Foreign
country under
laws of which
Principal
organized
business

Percentage
voting
securities
owned

21. Annex the latest regular periodic report filed with the superintend of insurance of the life insurers domicile and, if available,
submit in the form of an attached exhibit a copy of the life insurers last regular periodic report to its security holders or
policyholders.

Indent to show degree of remoteness from the insurer, for example –
Life Insurer
1

Company A (5% or more of voting securities of which held by life insurer)
Company B (5% or more of voting securities held by Company A)


SIGNATURE
Pursuant to Rule ______________ Under the Investment Company Act of 1940, the undersigned ___________________________
(Name of Separate Account) _____________________________ and ________________________________(Name of Life Insurer)
____________________________________ have caused this Notification of Claim of Exemption to be duly executed on behalf of the
separate account claiming exemption in the city of ______________________________, county of ____________________________,
state of ____________________________ on the ______________________, 20________.
Attest _______________________________________
__________________________________________
(Name)
(Name of Separate Account)
_______________________________________
By _______________________________________
(Title)
(Chairman of the Board of Directors)
Attest _______________________________________
By ________________________________________
(Name)
(Name of Life Insurer)
_______________________________________
By _______________________________________
(Title)
(Director, Trustee or Senior Officer)