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EXHIBIT I Rev. 9115 OAR 8360270100FORM A STATEMENT REGARDING THE ACQUISITION OF CONTROL OF OR MERGER WITHOUT HEALTH PLAN, INC. (the “Domestic Insurer “)BY DELTA DENTAL OF CALIFORNIA (the “Applicant
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To fill out a statement form, follow these steps:
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Start by clearly identifying the purpose of the statement.
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Include your personal information such as your name, address, and contact details.
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Use bullet points or numbered lists to present information systematically.
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Anyone who wants to communicate important information or make a formal declaration may need to fill out a statement form. This can include individuals involved in legal proceedings, individuals reporting an incident or providing a testimony, or individuals making a formal request or complaint. Employers, government agencies, educational institutions, and other organizations may also require individuals to fill out statement forms for various purposes.
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