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EXHIBIT 99.3
CAPITAL HOLDINGS, INC.
COMMUNITY OFFERING SUBSCRIPTION AGREEMENT
EXPIRATION DATE: DECEMBER 1, 1999
You may subscribe for shares of Capital Holdings, Inc. common stock
through a COMMUNITY OFFERING that begins October 15, 1999 and ends on December
1, 1999. This offering will only be available if any shares remain unsold after
our rights offering that we commenced on October 15, 1999 and ends on November
15, 1999. This offering will only be available if any shares remain unsold after
the rights offering. To participate in the COMMUNITY OFFERING, you must
subscribe for A MINIMUM OF 400 SHARES and complete the appropriate subscription
agreement, which is attached and include full payment for those shares as well.
Orders received in the community offering are subject to proration if the number
of shares ordered exceeds the number of shares remaining after the rights
offering. Also, orders in the community offering are subject to rejection in
whole or in part solely at our discretion.
To order shares in the community offering, we must receive a properly
completed and executed copy of this Subscription Agreement by December 1, 1999,
together with a personal check, cashier's check or money order payable to
"CAPITAL HOLDINGS, INC." for an amount equal to the number of shares subscribed
for multiplied by $27. The deadline for submitting the subscription agreement
and related payment in the community offering is DECEMBER 1, 1999.
FOR A MORE COMPLETE DESCRIPTION OF THE TERMS AND CONDITIONS OF THIS
OFFERING, PLEASE REFER TO THE PROSPECTUS DATED OCTOBER 11, 1999, WHICH IS
INCORPORATED HEREIN BY REFERENCE. COPIES OF THE PROSPECTUS ARE AVAILABLE UPON
REQUEST FROM CAPITAL HOLDINGS, INC. BY CALLING XXXXXXX X. XXXXXXX, SENIOR VICE
PRESIDENT, AT (000) 000-0000 OR(800) 366-5580.
EXERCISE AND SUBSCRIPTION: The undersigned hereby irrevocably
subscribes for the number of shares of common stock indicated below, on the
terms and subject to the conditions specified in the prospectus, receipt of
which is hereby acknowledged.
1. Number of shares you are subscribing for: (MINIMUM 400 SHARES) _______________
2. Total subscription price: (NUMBER OF SHARES IN LINE 1 TIMES $27) _______________
METHOD OF PAYMENT: Payment must be in the form of cashier's check,
certified check, money order, or personal check payable to "CAPITAL HOLDINGS,
INC."
If the aggregate amount enclosed is insufficient to purchase the total
number of shares listed in line 1, or if payment is enclosed but the number of
shares being subscribed for is not specified, the holder of this Subscription
Agreement shall be deemed to have subscribed for the maximum amount of shares
that could be subscribed for upon payment of such amount. Any remaining funds
shall be mailed to the subscriber without interest as soon as practicable.
Please indicate the form of ownership desired for the Shares:
_______ Individual _______ Corporation
_______ Joint Tenants with Right of Survivorship _______ Partnership
_______ Tenants in Common _______ Custodian
_______ Trust _______ Other (please describe):
__________________________________________________
PLEASE PRINT OR TYPE BELOW THE EXACT TITLING IN WHICH UNDERSIGNED
DESIRES THE COMMON SHARES TO BE REGISTERED:
________________________________________________________________________________
________________________________________________________________________________
_______________________________________________________ ___________________________________________________
Signature Date
_______________________________________________________ ___________________________________________________
Signature of Joint Owner, if applicable Area Code and Telephone Number
_______________________________________________________ ___________________________________________________
Street Address Social Security or Federal Taxpayer
Identification No.
_______________________________________________________ ___________________________________________________
(City) (State) (Zip)
TO BE COMPLETED BY CAPITAL HOLDINGS, INC.
Accepted as of _______________________ , 1999, as to __________ Shares.
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Xxxxxx X. Xxxxxxxx
President and Chief Operating Officer
[SEE REVERSE SIDE FOR SUBSTITUTE FORM W-9]
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SUBSTITUTE PART I - Taxpayer Identification
Form W-9 Number. For all accounts enter taxpayer (X)________________________________
number in the appropriate box. For most Social Security Number
individuals, this is your social security
Department of the Treasury number. If you do not have a number or if OR_________________________________
Internal Revenue Service the account is in more than one name, Employer Identification Number
contact the office identified in Instruction
Payer's Request for 6.
Taxpayer Identification
Number ("TIN")
PART II - For Payees Exempt from Backup Withholding
Certification - Under penalties of perjury, I certify that:
(1) The number shown on this form is my
correct Taxpayer Identification Number (or
I am waiting for a number to be issued to
me), and
(2) I am not subject to backup withholding
either because (a) I am exempt from backup
withholding; or (b) I have not been
notified by the Internal Revenue Service
("IRS") that I am subject to backup
withholding as a result of failure to
report all interest or dividends; or (c)
the IRS has notified me that I am no
longer subject to backup withholding.
CERTIFICATION GUIDELINES - You must
cross out item (2) above if you have been
notified by the IRS that you are subject to
backup withholding because of under-reporting
interest or dividends on your tax return.
However, if after being notified by the IRS
that you were subject to backup withholding you
received another notification from the IRS that
you are no longer subject to backup
withholding, do not cross out item (2).
Signature (X)________________________________________ Date _______________________, 1999
SUBSTITUTE FORM W-9. Each subscriber must provide a correct
taxpayer identification number ("TIN") and sign and date the Substitute
W-9 on the Transmittal. In general, if a subscriber is an individual, the
TIN is the social security number of such individual. See the enclosed
guidelines. If the correct TIN is not provided, the subscriber may be
subject to a $50 penalty imposed by the Internal Revenue Code. For
further information regarding instructions for completing the Substitute
Form W-9 (including how to obtain a TIN if you do not have one and how to
complete the Substitute Form W-9 if shares are held in more than one
name), contact Xxxxxxx X. Xxxxxxx, Senior Vice President, Capital
Holdings, Inc, 0000 Xxxxxx Xxxxxx, Xxxxxxxx, Xxxx 00000: (000) 000-0000
or (000) 000-0000.
