blanks (e) working group roll call

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Date: 10/28/21 Virtual Meeting BLANKS (E) WORKING GROUP Tuesday, November 16, 2021 12:00 – 1:00 p.m. ET / 11:00 a.m. – 12:00 p.m. CT / 10:00 – 11:00 a.m. MT / 9:00 – 10:00 a.m. PT

ROLL CALL Jake Garn, Chair Utah Patricia Gosselin New Hampshire Kim Hudson, Vice Chair California Nakia Reid/Mariam Awad New Jersey Wally Thomas Alaska Tracy Snow Ohio William Arfanis Connecticut Diane Carter Oklahoma Dave Lonchar Delaware Ryan Keeling Oregon N. Kevin Brown District of Columbia Kimberly Rankin/ Carolyn Morgan Florida Melissa Greiner Pennsylvania Roy Eft Indiana Trey Hancock Tennessee Daniel Mathis Iowa Shawn Frederick Texas Dan Schaefer Michigan Steve Drutz Washington Debbie Doggett/Danielle Smith Missouri Jamie Taylor West Virginia Lindsay Crawford/Justin Schrader Nebraska Adrian Jaramillo Wisconsin NAIC Support Staff: Mary Caswell/Calvin Ferguson/Julie Gann AGENDA 1. Consider Adoption of its July 22 Minutes—Jake Garn (UT) Attachment A 2. Consider Adoption of Items Previously Exposed—Jake Garn (UT)

a) 2021-11BWG Modified – Add a new annual statement supplement to the Property/Casualty (P/C) statement to capture exposure data for Annual Statement Lines 4, 19.1, 19.2, and 21.2 of the Exhibit of Premiums and Losses. Add a column to the Quarterly Parts 1 and 2 to capture exposure data for these annual statement lines for the quarter.

Attachment B

b) 2021-12BWG Modified – Add and delete lines on the Analysis of Operations

by Lines of Business - Accident and Health for Life\Fraternal to capture health specific data captured on the Heath Analysis of Operations by Lines of Business but not on the Life\Fraternal Analysis of Operations page and add new crosschecks for the new lines. Add new crosschecks to the Analysis of Operations by Lines of Business – Summary to map the lines on the accident and health (A&H) page to the summary.

Attachment C

c) 2021-13BWG Modified – Add a new supplement to capture premium and

loss data for Annual Statement Lines 17.1, 17.2, and 17.3 of the Exhibit of Premiums and Losses (State Page) – Other Liability by more granular lines of business.

Attachment D

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d) 2021-14BWG Modified – Expand the number of lines of business reported on Schedule H to match the lines of business reported on the Health Statement. Modify the instructions so they will be uniform between life/fraternal and property.

Attachment E

3. Consider New Items for Exposure—Jake Garn (UT)

a) 2021-15BWG – Add a footnote to Exhibit 7 in the Life/Fraternal statement and the Health statement (Life Supplement) to capture amount of Federal Home Loan Bank (FHLB) Funding Agreements reported in columns 1 through 6 of the exhibit (2021-16 SAPWG).

Attachment F

b) 2021-16BWG – For Note 9 – Income Taxes, remove the 9C illustration instructions for the DTA and DTL components which states that “reporting entities should disclose those items included as “Other” (Lines 2a13, 2e4, 3a5 and 3b3) as additional lines for those items greater than 5% in the printed/PDF filing document”, as the illustration is not set up to accommodate variable lines. Add formulas for calculation of total and subtotal on the illustration for 9C. For Note 15 – Leases, modify the illustrations to add a “Thereafter” line and add a formula for “Total” line.

Attachment G

c) 2021-17BWG – Modify the Analysis of Operations by Lines of Business in the

Health Blank to include all of health lines of business included in the Life/Fraternal Analysis of Operations by Lines of Business – Accident and Health. Add instructions for the new columns and adjust the column references. Add the Health Blank Analysis of Operations by Lines of Business as a supplement to the Life/Fraternal Blank with the appropriate instructions and crosschecks. Add crosscheck to the Health Blank Analysis of Operations by Lines of Business to the Life/Fraternal Analysis of Operations by Lines of Business – Accident and Health instructions

Attachment H

d) 2021-18BWG – Modify the Life Insurance (State Page) to include the line of

business detail reported on the Analysis of Operations by Lines of Business pages. Two new Schedule T style pages (Exhibit of Claims Settled During the Current Year and Policy Exhibit) are created to include detail captured by state on the existing Life Insurance (State Page) that could not be included due space issue. Add definitions for life and annuity products to the lines of business definitions in the health appendix.

Attachment I

e) 2021-19BWG – Add columns and lines to U&I (Parts 1, 2, 2A, 2B, and 2D)

and the Exhibit of Premiums, Enrollment and Utilization in the annual statement bring the lines of business reporting in line with Life/Fraternal and Property. Add columns and lines to the Exhibit of Premiums, Enrollment and Utilization and U&I Analysis of Claims Unpaid quarterly pages. The appropriate adjustments to the instructions are also being made.

Attachment J

f) 2021-20BWG – Starting at Line 72 of the Life/Fraternal Five-Year Historical

add or delete lines that do not pull in the specific lines of business reported on the Life/Fraternal Analysis of Operations by Lines of Business detail pages

Attachment K

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https://naiconline.sharepoint.com/teams/frsblanks/meetings and calls/2021/2021.11.16 - call/bwg 11 2021 agenda.docx

for life (individual and group), annuities (individual and group), and A&H for Line 33 of those pages.

g) 2021-21BWG – Add instruction to the Investment Schedules General

Instructions to exclude non-rated residual tranches or interests from being reported as bonds on Schedule D, Part 1 and add lines to Schedule BA for the reporting of those investments (2021-15 SAPWG).

Attachment L

Attachment M 4. Consider Adoption of the Editorial Listing—Jake Garn (UT) Attachment N 5. Approve State Filing Checklists—Jake Garn (UT) 6. Discuss Any Other Matters Brought Before the Working Group—Jake Garn (UT) 7. Adjournment

The following documents are being provided as reference materials: Summary of Comment Letters Attachment O Comment Letters Attachment P

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Attachment A

© 2021 National Association of Insurance Commissioners 1

Draft: 8/3/21

Blanks (E) Working Group Virtual Meeting July 22, 2021

The Blanks (E) Working Group of the Accounting Practices and Procedures (E) Task Force met July 22, 2021. The following Working Group members participated: Jake Garn, Chair (UT); Kim Hudson, Vice Chair (CA); William Arfanis (CT); N. Kevin Brown (DC); Carolyn Morgan (FL); Daniel Mathis (IA); Roy Eft (IN); Dan Schaefer (MI); Lindsay Crawford (NE); Patricia Gosselin (NH); Mariam Awad and Nakia Reid (NJ); Diane Carter (OK); Melissa Greiner and Kimberly Rankin (PA); Trey Hancock (TN); Shawn Frederick (TX); Steve Drutz (WA); Randy Milquet (WI); and Jamie Taylor (WV). Also participating: Phil Vigliaturo (MN). 1. Adopted its May 26 Minutes Mr. Garn said the Blanks (E) Working Group met May 26 and took the following action: 1) adopted eight blanks proposals: a) 2021-01BWG, add reference to health care receivables line in the Asset page; b) 2021-02BWG, add questions to the General Interrogatories, Part 1 regarding depository institution holding companies as it pertains to the group capital calculation (GCC); c) 2021-03BWG, add category lines to the Separate Accounts General Interrogatories for additional granularity; d) 2021-04BWG, add a General Interrogatory to identify insurers that use third parties to pay agent commissions in which the amounts advanced by the third parties are not settled in full within 90 days; e) 2021-05BWG, modify Note 17B(4) to reflect changes made by the Statutory Accounting Principles (E) Working Group reference number SAPWG 2021-03 regarding transferred assets; f) 2021-06BWG, add crosschecks to the long-term care (LTC) reporting forms to gain consistency; g) 2021-07BWG, add additional line categories to capture collateral type data for all residential mortgage-backed securities (RMBS), commercial mortgage-backed securities (CMBS), and loan-backed and structured securities (LBSS) securities regardless of reporting category; and h) 2021-08BWG, add a new supplement Mortgage Guaranty insurance Exhibit to capture more information from mortgage guaranty insurers; 2) adopted its editorial listing; and 3) exposed five proposals for public comment. Mr. Eft made a motion, seconded by Ms. Reid, to adopt the Working Group’s May 26 minutes (Attachment Two-A). The motion passed unanimously. 2. Adopted Proposals Previously Exposed

a . Agenda Item 2021-10BWG – Effective Jan.1, 2022 Mr. Hudson stated that this proposal removes language in the quarterly General Interrogatories Part 1, line 4.1 that requires the filing of a quarterly merger/history form. Proposal 2017-21BWG added language to the General Interrogatories to require filing a merger/history form for annual and quarterly statements. The annual form works as intended. It is used for Insurance Regulatory Information System (IRIS) calculations, as well as validations. He stated that the quarterly form does not function with the database system as currently designed. Therefore, the requirement to file quarterly should be removed. The annual form will still be required. There were no interested party comments received for this proposal. Mr. Hudson made a motion, seconded by Mr. Drutz, to adopt the proposal. The motion passed unanimously (Attachment Two-B). 3. Deferred Proposals Previously Exposed

a . Agenda Item 2021-11BWG Birny Birnbaum (Center for Economic Justice—CEJ) stated that this proposal adds the data capture elements of direct written exposures and direct earned exposures for the personal lines of business of homeowners and private passenger auto (PPA) to the annual and quarterly statements for the Property and Casualty blank. He stated that this proposal was discussed during a meeting of the Casualty Actuarial and Statistical (C) Task Force. The Task Force asked for a revision to line 4 of the annual statement instructions for homeowners to exclude renters, condominiums and co-ops. Tip Tipton (Thrivent Financial) stated that interested parties recommend that this proposal be rejected and returned to the Casualty Actuarial and Statistical (C) Task Force because this is statistical data and inconsistent with the responsibilities of the Blanks (E) Working Group. He stated that there are two distinct processes being referenced. One is the reporting of financial data for solvency that is located in the annual and quarterly statement filings. The other is statistical data found in the various

Attachment A


statistical reports. He stated that interested parties are concerned with incorporating statistical data into the annual statement filing and potentially opening a Pandora’s box for more such statistical data. He stated that the Casualty Actuarial and Statistical (C) Task Force’s vote of nine to 17 for rejection of the proposal suggests that some state insurance regulators do not see the need for this data within the annual statement. Mr. Tipton stated that interested parties support the Task Force request to determine the reason the statistical report takes two years to accumulate the information and release. Rachel Underwood (Cincinnati Insurance Companies) stated that it was suggested that this proposal was aimed at getting average premium per exposure for the Casualty Actuarial and Statistical (C) Task Force reports quicker. She stated that, however, the proposal asks for company-level detail and new statistical data that is not found in those reports today. The current reports contain narrative content regarding things such as data sources, limitations, and exclusion of data factors that affect the cost of insurance. She stated that it is unreasonable to think that all the pertinent and relevant data from these two reports should or could be incorporated into the annual statement. Ms. Underwood stated that companies do not have the written exposure counts readily available. The fastest growing personal automobile insurer does not provide exposure counts on a monthly basis, which she states is proprietary information. She stated that there are also issues related to the COVID-19 pandemic where companies gave relief payments. Some states had moratoriums on lapses due to nonpayment of premium. Derek Freihaut (Pinnacle Actuarial Resources) stated that there should be a clear definition of “exposure.” Comparisons may not be accurate when looking at average premiums related to the various mixes of exposures over time and comparing against different companies. Another concern he expressed is that this is statistical data, which can be difficult to pull over to the financial data and have a true comparison. He suggests that there be additional work performed to develop clear specifications on the data request and better definitions to minimize distortions. If the proposal did move forward, he suggests it be considered for a 2023 annual implementation. Mr. Vigliaturo, chair of the Casualty Actuarial and Statistical (C) Task Force, stated that the problem is that this information is based on rate service organizations. With that, there are significant delays in obtaining the information and compiling it for the reports. There are at least four organizations to which companies report this data. With the way things are done currently, it is unrealistic to accelerate the production of these reports. Mr. Birnbaum stated that the information is typically delayed when comparing premiums and losses in that the losses develop over a period of time. He stated that the information does not come from only statistical agents but from several states as well. He stated that there are delays for the time needed to compile the data. Mr. Birnbaum stated that the request for this data is not for rate making but for financial and market analysis purposes. The annual statement is the best mechanism for collecting this type of data. The Casualty Actuarial and Statistical (C) Task Force does not have the same mechanism to collect this data. He stated that he does not agree with the claims that the data would be misleading as it is just the data elements. It would be whatever analysis the user performs that could potentially be misleading. Jonathan Rodgers (National Association of Mutual Insurance Companies—NAMIC) stated that there is a question as to whether there is a regulatory need for this information and how it will be used for solvency monitoring. He indicated that this proposal should be rejected as state insurance regulators are currently able to obtain this information from statistical agents and within Schedule P of the annual statement filing. He agreed, however, with the re-exposure and referral to the financial analysis groups if this proposal does move forward. Mr. Hudson made a motion, seconded by Mr. Mathis, to adopt the modifications to the proposal. The motion passed unanimously. Mr. Hudson made a motion, seconded by Mr. Drutz, to re-expose the modified proposal for a 90-day public comment period ending Oct. 22, send a copy of the proposal to the Casualty Actuarial and Statistical (C) Task Force for review, and send a referral to the Financial Analysis (E) Working Group and Financial Analysis Solvency Tools (E) Working Group for comment. The motion passed unanimously.

b. Agenda Item 2021-12BWG

Mr. Garn stated that this proposal modifies lines on the Analysis of Operations by Lines of Business - Accident and Health for Life/Fraternal to capture health-specific data consistent with that of the heath blank Analysis of Operations by Lines of Business, as well as adding crosschecks for the new lines. The change allows for more consistent information to be collected with that of the Health blank. He stated that there are some modifications to the proposal that were suggested, as well as a request for more time to review and provide additional comments. Mr. Hudson made a motion, seconded by Mr. Drutz, to adopt the modifications to the proposal. The motion passed unanimously. Mr. Drutz made a motion, seconded by Mr. Hudson, to defer the modified proposal for a 90-day comment period ending Oct. 22. The motion passed unanimously.

Attachment A


c. Agenda Item 2021-13BWG Ms. Gosselin stated that this proposal adds a new supplement to capture premium and loss data for annual statement lines 17.1, 17.2 and 17.3 of the Exhibit of Premiums and Losses (State Page) – Other Liability to add more granular lines of business. The purpose is to provide state insurance regulators with greater detail of business reported in the aggregate “other liability” category. She stated that the Casualty Actuarial and Statistical (C) Task Force reviewed this proposal and indicated that it is in favor of the proposal with or without modification. The Casualty Actuarial and Statistical (C) Task Force suggested one modification to change the incurred but not reported (IBNR) to “case reserves” because the IBNR is likely not available at this level of detail. There were four interested party comments related to the proposal, as well as a request by interested parties to have more time to review the proposal and provide additional comments. Ms. Gosselin made a motion, seconded by Mr. Hudson, to adopt the modifications to the proposal, including the Casualty Actuarial and Statistical (C) Task Force request to change IBNR to “case reserves.” The motion passed unanimously. Ms. Gosselin made a motion, seconded by Mr. Milquet, to defer the modified proposal for a 90-day comment period ending Oct. 22. The motion passed unanimously.

d. Agenda Item 2021-14BWG

Mr. Frederick stated that this proposal expands the number of lines of business reported on Schedule H to match the lines of business reported on the Health Statement. The purpose of the proposal is to bring uniformity in the accident and health (A&H) lines of business used on Schedule H with other schedules and exhibits in the annual statement. Interested parties provided comments asking for additional time to consider the impacts to the Life/Fraternal blank and Property/Casualty blank. He stated that with the effective date of annual 2022, there is time to defer for further consideration if the state insurance regulators want to allow. Mr. Frederick stated that there are minor modifications to the proposal. Mr. Frederick made a motion, seconded by Mr. Hudson, to adopt the modifications to the proposal. The motion passed unanimously. Mr. Frederick made a motion, seconded by Mr. Eft, to defer the modified proposal for a 90-day comment period ending Oct. 22. The motion passed unanimously. 4. Adopted the Editorial Listing Mr. Garn stated that there has been a request to make some additional editorial changes related to the Mortgage Guaranty Supplement. Andy Daleo (NAIC) stated that there are three clarifying modifications needed to the Mortgage Guaranty Supplement that the Working Group adopted during its May 26 meeting, proposal 2021-08BWG. He stated that the changes are clarifying in nature for the users. The proposed editorial changes consist of: 1) removing the word “Total” from column 23, which reads “Total net adjusting and other expenses unpaid.” The true “Total” column is column 24 of Part 1A and Part 1B of the exhibit; 2) change the column 32 heading in Part 1A and Part 1B from “Net Loss and LAE Coverage” to “Net Loss and LAE as a % of Original Risk in Force” to clarify the intended reporting; and 3) remove column 33 “Net Reserves” in Part 1A and Part 1B as it requests duplicative information of that shown in column 24 “Total net losses and LAE unpaid.” Mr. Hudson made a motion, seconded by Ms. Taylor, to adopt the editorial listing, including the additional changes to the Mortgage Guaranty Supplement requested (Attachment Two-C). The motion passed unanimously. 5. Adopted Health Actuarial Statement of Opinion Guidance for the 2021 Reporting Year Mr. Eft made a motion, seconded by Mr. Hudson, to adopt the Health Actuarial Statement of Opinion guidance for year-end 2021 reporting and approve the posting to the Blanks (E) Working Group website (Attachment Two-D). The motion passed unanimously. Having no further business, the Blanks (E) Working Group adjourned. w:\national meetings\2021\summer\tf\app\blankswg\minutes\att two_7.22.2021 blanks.docx

Attachment B

© 2021 National Association of Insurance Commissioners 2021-11BWG.doc 1

NAIC BLANKS (E) WORKING GROUP

Blanks Agenda Item Submission Form

DATE: 04/15/2021

CONTACT PERSON: Birny Birnbaum

TELEPHONE: 512 784 7663

EMAIL ADDRESS: [email protected] ON BEHALF OF: Center for Economic Justice

NAME: Birny Birnbaum

TITLE: Director

AFFILIATION: NAIC Designated Consumer Representative

ADDRESS: 1701A South Second St

Austin, TX 78704

FOR NAIC USE ONLY Agenda Item # 2021-11BWG Year 2022 Changes to Existing Reporting [ X ] New Reporting Requirement [ ]

REVIEWED FOR ACCOUNTING PRACTICES AND PROCEDURES IMPACT

No Impact [ X ] Modifies Required Disclosure [ ]

DISPOSITION [ ] Rejected For Public Comment [ X ] Referred To Another NAIC Group CASTF, FAWG and FAST [ ] Received For Public Comment [ ] Adopted Date [ ] Rejected Date [ X ] Deferred Date 07/22/2021 [ ] Other (Specify)

BLANK(S) TO WHICH PROPOSAL APPLIES

[ X ] ANNUAL STATEMENT [ X ] INSTRUCTIONS [ X ] CROSSCHECKS [ X ] QUARTERLY STATEMENT [ X ] BLANK

[ ] Life, Accident & Health/Fraternal [ ] Separate Accounts [ ] Title [ X ] Property/Casualty [ ] Protected Cell [ ] Other ___________________ [ ] Health [ ] Health (Life Supplement)

Anticipated Effective Date: Annual 2022

IDENTIFICATION OF ITEM(S) TO CHANGE Add a new annual statement supplement to capture exposure data for Annual Statement Lines 4, 19.1, 19.2 and 21.2. Add a column to the Quarterly Parts 1 and 2 to capture exposure data for these annual statement lines for the quarter.

***See Next Page For More Details***

REASON, JUSTIFICATION FOR AND/OR BENEFIT OF CHANGE**

***See Next Page For Details***

NAIC STAFF COMMENTS Comment on Effective Reporting Date: Other Comments: ___________________________________________________________________________________________________ ** This section must be completed on all forms. Revised 7/18/2018

Attachment B


IDENTIFICATION OF ITEM(S) TO CHANGE Add a new annual statement supplement to the Property and Casualty annual statement to capture “Direct Exposures Written” and “Direct Exposures Earned” which will be reported, initially only for Annual Statement Lines 4 (Homeowners), 19.1 (PPA No Fault), 19.2 (PPA Liability) and 21.1 (PPA Physical Damage). Add one column to property casualty quarterly statement Part 1 Loss experience between current columns 1 and 2 for “Direct Exposures Earned” only for only for Lines 4 (Homeowners), 19.1 (PPA No Fault), 19.2 (PPA Liability) and 21.1 (PPA Physical Damage). Add one column to property casualty quarterly statement Part 2 Direct Premium Written between current columns 1 and 2 for “Direct Exposures Written” only for only for Lines 4 (Homeowners), 19.1 (PPA No Fault), 19.2 (PPA Liability) and 21.1 (PPA Physical Damage). Add instructions for reporting the additional data elements, consisting of definitions and examples for the new data elements.

REASON, JUSTIFICATION FOR AND/OR BENEFIT OF CHANGE** The average written and average earned premium per exposure is an important metric for a variety of regulatory and public policy purposes. The NAIC annually produces reports of average personal auto and homeowners premiums, but the data in these reports are old and stale for timely assessment of absolute average premium and changes in average premium over time. Both reports are typically produced 24 months after the end of the experience period and 36 months after the beginning of the experience period. Homeowners average premiums for 2018 was published in January 2021 in the “Dwelling Fire, Homeowners Owner-Occupied, and Homeowners Tenant and Condominium/Cooperative Unit Owners’ Insurance Report: Data for 2018.” Personal auto average premiums for 2018 was published in March 2021 in the “Auto Database Report.” While there are valid reasons for the length of time needed to produce these reports – primarily because these reports contain information beyond average premium – the average premium numbers lose significant relevance because of their age. This AS and QS Blanks proposals would allow the calculation of average written and average earned premium for residential property and personal auto coverages in a far more timely fashion – within three to four months following the reporting year instead of 24 months and would provide timely and useful quarterly information. The benefits of timelier average premium data are considerable. Timely average premium data would permit financial analysts to utilize changes in average premium as part of financial analysis. Similarly, the more-timely average premium data would become a valuable tool for market regulation analysts, including, but not limited to, an added data point for use with the Market Conduct Annual Statement. Last, but not least, this proposal would allow the NAIC to calculate and publish average annual premium data for residential property and personal auto insurance by state in a time frame to both make the data meaningful for describing market conditions and to inform individual state regulators and policymakers of actual changes in personal lines average premiums – as opposed to expected changes gleaned from rate filings. Consider how valuable timely average premium values would have been for personal lines as the pandemic unfolded. Consider also the value of quarterly data for average premium for personal lines versus only an annual average. The lack of timeliness of the average premium values means that these data have very limited or no use for either financial or market analysis. The lack of timeliness also means that the data are no use in informing public policy debates about personal lines insurance costs. In addition, the severe time lag between actual experience and reporting fails to inform the public or policymakers of recent trends or outcomes and can, consequently, mislead the public and policymakers.

Attachment B


ANNUAL STATEMENT INSTRUCTIONS – PROPERTY

DIRECT PREMIUM AND EXPOSURES Annual Statement Lines 2.5, 4, 19.1, 19.2 and 21.1

Allocated by States and Territories This supplement must be filed with the NAIC by March 1 each year. This supplement should be completed by those reporting entities that write direct business reported on the Exhibit of Premiums and Losses for each Annual Statement Lines (ASL) listed below. A separate page will be completed for each ASL.

ASL 4 (Homeowners)

Excluding Renters, Condominiums and Co-ops

Renters, Condominiums and Co-ops

ASL 19.1 (Private Passenger Auto No-Fault – Personal Injury Protection)

ASL 19.2 (Other Private Passenger Auto Liability)

ASL 21.1 (Private Passenger Auto Physical Damage). Column 1 – Direct Premiums Written

The amounts reported for each line should agree with the amounts reported for the corresponding Annual Statement Line in Column 1, Line 35 of the Exhibit of Premiums and Losses for that state.

Line 59 (Part 1 plus Part 2) should equal Line 4, Column 1, Line 35 of the Exhibit of Premiums and Losses (GT Page)

Line 59 (Part 3) should equal Line 19.1, Column 1, Line 35 of the Exhibit of Premiums and Losses (GT Page)



Column 2 – Direct Written Exposures

A Written Exposure for Annual Statement Lines 4 is defined as a single residential property for which coverage was written at any time during the calendar reporting period and remained in force through the end of the calendar reporting year. If the coverage was written and cancelled within the calendar reporting year, the written exposure is the fraction of the year the coverage was in force.

A Written exposure for Annual Statement Lines 19.1, 19.2 and 21.1 is defined as single motor vehicle for which coverage was written at any time during the calendar reporting year and remained in force through the end of the calendar reporting year. If the coverage was written and cancelled within the calendar reporting year, the written exposure is the fraction of the year the coverage was in force.

Attachment B


Examples. Assume a homeowners policy is written on July 1 during the reporting year and remains in force through the end of the reporting year. This activity would be reported as one (1.0) written exposure.

Assume a private passenger policy with No-Fault, Liability and Physical Damage coverages was written on April 1 and cancelled by the insured on July 1. This activity would be reported as 0.25 written exposure.

Column 3 – Direct Premiums Earned

The amounts reported for each line should agree with the amounts reported for the corresponding Annual Statement Line in Column 2, Line 35 of the Exhibit of Premiums and Losses for each state.

Line 59 (Part 1 plus Part 2) should equal Line 4, Column 2, Line 35 of the Exhibit of Premiums and Losses (GT Page)




Column 4 – Direct Earned Exposures

An Earned Exposure for Annual Statement Lines 4 is defined as the fraction of the calendar reporting year for which a single residential property had coverage in force.

An Earned Exposure for Annual Statement Lines 19.1, 19.2 and 21.2 is defined as the fraction of the calendar reporting year for which a single motor vehicle had coverage in force.

Examples. Assume a homeowners policy is written on July 1 during the reporting year and

remains in force through the end of the reporting year. This activity would be reported as 0.5 earned exposure.

Assume a private passenger policy with No-Fault, Liability and Physical Damage coverages was written on April 1 and cancelled by the insured on July 1. This activity would be reported as 0.25 earned exposure.

Attachment B


QUARTERLY STATEMENT INSTRUCTIONS – PROPERTY

PART 1 – LOSS EXPERIENCE Column 1 – Direct Premiums Earned

Display direct premiums earned by line of business. The total must agree with the Statement of Income Page 4, Direct Premiums Earned Line 1.1, Column 1.

Column 2 – Direct Earned Exposures

An Earned Exposure for Annual Statement Lines 4 is defined as the fraction of the calendar reporting year for which a single residential property had coverage in force.

An Earned Exposure for Annual Statement Lines 19.1, 19.2 and 21.2 is defined as the fraction of the calendar reporting year for which a single motor vehicle had coverage in force.


remains in force through the end of the reporting year. This activity would be reported as 0.5 earned exposure.

Assume a private passenger policy with No-Fault, Liability and Physical Damage coverages was written on April 1 and cancelled by the insured on July 1. This activity would be reported as 0.25 earned exposure.

Column 23 – Direct Losses Incurred

Display direct losses incurred by line of business. The total must agree with the Statement of Income Page 4, Direct Losses Incurred Line 2.1, Column 1.

Column 34 – Direct Loss Percentage

Column 2 3 (Direct Losses Incurred)/Column 1 (Direct Premiums Earned) multiplied by 100. Column 45 – Prior Year to Date Direct Loss Percentage

Display year-to-date direct loss percentages by line of business for the same quarter of the prior year. Line 30 – Warranty

Data for this line should be reported prospectively (i.e., Prior year amounts need not be restated) starting with the 2008 reporting year.

Attachment B


PART 2 – DIRECT PREMIUMS WRITTEN Column 1 – Current Quarter

Display current quarter direct premiums written by line of business. Column 2 – Direct Written Exposures

A Written Exposure for Annual Statement Lines 4 is defined as a single residential property for which coverage was written at any time during the calendar reporting period and remained in force through the end of the calendar reporting year. If the coverage was written and cancelled within the calendar reporting year, the written exposure is the fraction of the year the coverage was in force.

A Written exposure for Annual Statement Lines 19.1, 19.2 and 21.1 is defined as single motor vehicle for which coverage was written at any time during the calendar reporting year and remained in force through the end of the calendar reporting year. If the coverage was written and cancelled within the calendar reporting year, the written exposure is the fraction of the year the coverage was in force.


remains in force through the end of the reporting year. This activity would be reported as one (1.0) written exposure.

Assume a private passenger policy with No-Fault, Liability and Physical Damage coverages was written on April 1 and cancelled by the insured on July 1. This activity would be reported as 0.25 written exposure.

Column 23 – Current Year to Date

Display year-to-date direct premiums written. Column 34 – Prior Year, Year to Date

Display year-to-date direct premiums written from the same quarter of the prior year. Line 30 – Warranty

Data for this line should be reported prospectively (i.e., Prior year amounts need not be restated) starting with the 2008 reporting year.

Attachment B


ANNUAL STATEMENT BLANK – PROPERTY

DIRECT PREMIUM AND EXPOSURES Allocated by States and Territories

For The Year Ended December 31, 20__ (To Be Filed by March 1)

Part 1 – Homeowners (Excluding Renters, Condominiums and Co-ops) Annual Statement Line 4

1 2 3 4

Direct Premiums

Written Direct Exposures

Written Direct Premiums

Earned Direct Exposures

Earned 1. Alabama ........................................................................... AL ............................. .............................. .............................. .............................. 2. Alaska .............................................................................. AK ............................. .............................. .............................. .............................. 3. Arizona ............................................................................ AZ ............................. .............................. .............................. .............................. 4. Arkansas .......................................................................... AR ............................. .............................. .............................. .............................. 5. California ......................................................................... CA ............................. .............................. .............................. .............................. 6. Colorado .......................................................................... CO ............................. .............................. .............................. .............................. 7. Connecticut ....................................................................... CT ............................. .............................. .............................. .............................. 8. Delaware .......................................................................... DE ............................. .............................. .............................. .............................. 9. District of Columbia ........................................................ DC ............................. .............................. .............................. .............................. 10. Florida ............................................................................... FL ............................. .............................. .............................. .............................. 11. Georgia ............................................................................ GA ............................. .............................. .............................. .............................. 12. Hawaii ................................................................................HI ............................. .............................. .............................. .............................. 13. Idaho ..................................................................................ID ............................. .............................. .............................. .............................. 14. Illinois ................................................................................ IL ............................. .............................. .............................. .............................. 15. Indiana ...............................................................................IN ............................. .............................. .............................. .............................. 16. Iowa ...................................................................................IA ............................. .............................. .............................. .............................. 17. Kansas ............................................................................... KS ............................. .............................. .............................. .............................. 18. Kentucky .......................................................................... KY ............................. .............................. .............................. .............................. 19. Louisiana ......................................................................... LA ............................. .............................. .............................. .............................. 20. Maine ............................................................................... ME ............................. .............................. .............................. .............................. 21. Maryland ......................................................................... MD ............................. .............................. .............................. .............................. 22. Massachusetts ................................................................. MA ............................. .............................. .............................. .............................. 23. Michigan ........................................................................... MI ............................. .............................. .............................. .............................. 24. Minnesota ....................................................................... MN ............................. .............................. .............................. .............................. 25. Mississippi ....................................................................... MS ............................. .............................. .............................. .............................. 26. Missouri .......................................................................... MO ............................. .............................. .............................. .............................. 27. Montana ........................................................................... MT ............................. .............................. .............................. .............................. 28. Nebraska .......................................................................... NE ............................. .............................. .............................. .............................. 29. Nevada ............................................................................. NV ............................. .............................. .............................. .............................. 30. New Hampshire ............................................................... NH ............................. .............................. .............................. .............................. 31. New Jersey ........................................................................ NJ ............................. .............................. .............................. .............................. 32. New Mexico ................................................................... NM ............................. .............................. .............................. .............................. 33. New York ........................................................................ NY ............................. .............................. .............................. .............................. 34. North Carolina ................................................................. NC ............................. .............................. .............................. .............................. 35. North Dakota .................................................................. ND ............................. .............................. .............................. .............................. 36. Ohio ................................................................................. OH ............................. .............................. .............................. .............................. 37. Oklahoma ......................................................................... OK ............................. .............................. .............................. .............................. 38. Oregon ............................................................................. OR ............................. .............................. .............................. .............................. 39. Pennsylvania ..................................................................... PA ............................. .............................. .............................. .............................. 40. Rhode Island ...................................................................... RI ............................. .............................. .............................. .............................. 41. South Carolina .................................................................. SC ............................. .............................. .............................. .............................. 42. South Dakota .................................................................... SD ............................. .............................. .............................. .............................. 43. Tennessee ........................................................................ TN ............................. .............................. .............................. .............................. 44. Texas ................................................................................ TX ............................. .............................. .............................. .............................. 45. Utah.................................................................................. UT ............................. .............................. .............................. .............................. 46. Vermont ........................................................................... VT ............................. .............................. .............................. .............................. 47. Virginia ............................................................................ VA ............................. .............................. .............................. .............................. 48. Washington ..................................................................... WA ............................. .............................. .............................. .............................. 49. West Virginia .................................................................. WV ............................. .............................. .............................. .............................. 50. Wisconsin ......................................................................... WI ............................. .............................. .............................. .............................. 51. Wyoming ........................................................................ WY ............................. .............................. .............................. .............................. 52. American Samoa .............................................................. AS ............................. .............................. .............................. .............................. 53. Guam ............................................................................... GU ............................. .............................. .............................. .............................. 54. Puerto Rico ....................................................................... PR ............................. .............................. .............................. .............................. 55. US Virgin Islands ..............................................................VI ............................. .............................. .............................. .............................. 56. Northern Mariana Islands ................................................ MP ............................. .............................. .............................. .............................. 57. Canada .......................................................................... CAN ............................. .............................. .............................. .............................. 58. Aggregate Other Alien .................................................... OT 59. Total

Attachment B


Part 2 – Homeowners (Renters, Condominiums and Co-ops) Annual Statement Line 4

1 2 3 4

Direct Premiums




Earned 1. Alabama ........................................................................... AL .............................. .............................. .............................. ............................. 2. Alaska .............................................................................. AK .............................. .............................. .............................. ............................. 3. Arizona ............................................................................ AZ .............................. .............................. .............................. ............................. 4. Arkansas .......................................................................... AR .............................. .............................. .............................. ............................. 5. California ......................................................................... CA .............................. .............................. .............................. ............................. 6. Colorado .......................................................................... CO .............................. .............................. .............................. ............................. 7. Connecticut .......................................................................CT .............................. .............................. .............................. ............................. 8. Delaware .......................................................................... DE .............................. .............................. .............................. ............................. 9. District of Columbia ........................................................ DC .............................. .............................. .............................. ............................. 10. Florida ............................................................................... FL .............................. .............................. .............................. ............................. 11. Georgia ............................................................................ GA .............................. .............................. .............................. ............................. 12. Hawaii ............................................................................... HI .............................. .............................. .............................. ............................. 13. Idaho ................................................................................. ID .............................. .............................. .............................. ............................. 14. Illinois ................................................................................ IL .............................. .............................. .............................. ............................. 15. Indiana .............................................................................. IN .............................. .............................. .............................. ............................. 16. Iowa .................................................................................. IA .............................. .............................. .............................. ............................. 17. Kansas ...............................................................................KS .............................. .............................. .............................. ............................. 18. Kentucky .......................................................................... KY .............................. .............................. .............................. ............................. 19. Louisiana .......................................................................... LA .............................. .............................. .............................. ............................. 20. Maine ............................................................................... ME .............................. .............................. .............................. ............................. 21. Maryland ......................................................................... MD .............................. .............................. .............................. ............................. 22. Massachusetts ................................................................. MA .............................. .............................. .............................. ............................. 23. Michigan ........................................................................... MI .............................. .............................. .............................. ............................. 24. Minnesota ....................................................................... MN .............................. .............................. .............................. ............................. 25. Mississippi ....................................................................... MS .............................. .............................. .............................. ............................. 26. Missouri .......................................................................... MO .............................. .............................. .............................. ............................. 27. Montana ........................................................................... MT .............................. .............................. .............................. ............................. 28. Nebraska .......................................................................... NE .............................. .............................. .............................. ............................. 29. Nevada ............................................................................. NV .............................. .............................. .............................. ............................. 30. New Hampshire ............................................................... NH .............................. .............................. .............................. ............................. 31. New Jersey ........................................................................ NJ .............................. .............................. .............................. ............................. 32. New Mexico.................................................................... NM .............................. .............................. .............................. ............................. 33. New York ......................................................................... NY .............................. .............................. .............................. ............................. 34. North Carolina ................................................................. NC .............................. .............................. .............................. ............................. 35. North Dakota .................................................................. ND .............................. .............................. .............................. ............................. 36. Ohio ................................................................................. OH .............................. .............................. .............................. ............................. 37. Oklahoma ......................................................................... OK .............................. .............................. .............................. ............................. 38. Oregon ............................................................................. OR .............................. .............................. .............................. ............................. 39. Pennsylvania .....................................................................PA .............................. .............................. .............................. ............................. 40. Rhode Island ...................................................................... RI .............................. .............................. .............................. ............................. 41. South Carolina .................................................................. SC .............................. .............................. .............................. ............................. 42. South Dakota ....................................................................SD .............................. .............................. .............................. ............................. 43. Tennessee ........................................................................ TN .............................. .............................. .............................. ............................. 44. Texas ................................................................................ TX .............................. .............................. .............................. ............................. 45. Utah .................................................................................. UT .............................. .............................. .............................. ............................. 46. Vermont ........................................................................... VT .............................. .............................. .............................. ............................. 47. Virginia ............................................................................ VA .............................. .............................. .............................. ............................. 48. Washington ..................................................................... WA .............................. .............................. .............................. ............................. 49. West Virginia .................................................................. WV .............................. .............................. .............................. ............................. 50. Wisconsin .........................................................................WI .............................. .............................. .............................. ............................. 51. Wyoming ........................................................................ WY .............................. .............................. .............................. ............................. 52. American Samoa ...............................................................AS .............................. .............................. .............................. ............................. 53. Guam ................................................................................ GU .............................. .............................. .............................. ............................. 54. Puerto Rico ....................................................................... PR .............................. .............................. .............................. ............................. 55. US Virgin Islands ............................................................. VI .............................. .............................. .............................. ............................. 56. Northern Mariana Islands ................................................ MP .............................. .............................. .............................. ............................. 57. Canada .......................................................................... CAN .............................. .............................. .............................. ............................. 58. Aggregate Other Alien .................................................... OT 59. Total

Attachment B


Part 3 – Private Passenger Auto No-Fault (Personal Injury Protection) Annual Statement Line 19.1

1 2 3 4

Direct Premiums




Earned 1. Alabama ........................................................................... AL .............................. .............................. .............................. ............................. 2. Alaska .............................................................................. AK .............................. .............................. .............................. ............................. 3. Arizona ............................................................................ AZ .............................. .............................. .............................. ............................. 4. Arkansas .......................................................................... AR .............................. .............................. .............................. ............................. 5. California ......................................................................... CA .............................. .............................. .............................. ............................. 6. Colorado .......................................................................... CO .............................. .............................. .............................. ............................. 7. Connecticut .......................................................................CT .............................. .............................. .............................. ............................. 8. Delaware .......................................................................... DE .............................. .............................. .............................. ............................. 9. District of Columbia ........................................................ DC .............................. .............................. .............................. ............................. 10. Florida ............................................................................... FL .............................. .............................. .............................. ............................. 11. Georgia ............................................................................ GA .............................. .............................. .............................. ............................. 12. Hawaii ............................................................................... HI .............................. .............................. .............................. ............................. 13. Idaho ................................................................................. ID .............................. .............................. .............................. ............................. 14. Illinois ................................................................................ IL .............................. .............................. .............................. ............................. 15. Indiana .............................................................................. IN .............................. .............................. .............................. ............................. 16. Iowa .................................................................................. IA .............................. .............................. .............................. ............................. 17. Kansas ...............................................................................KS .............................. .............................. .............................. ............................. 18. Kentucky .......................................................................... KY .............................. .............................. .............................. ............................. 19. Louisiana .......................................................................... LA .............................. .............................. .............................. ............................. 20. Maine ............................................................................... ME .............................. .............................. .............................. ............................. 21. Maryland ......................................................................... MD .............................. .............................. .............................. ............................. 22. Massachusetts ................................................................. MA .............................. .............................. .............................. ............................. 23. Michigan ........................................................................... MI .............................. .............................. .............................. ............................. 24. Minnesota ....................................................................... MN .............................. .............................. .............................. ............................. 25. Mississippi ....................................................................... MS .............................. .............................. .............................. ............................. 26. Missouri .......................................................................... MO .............................. .............................. .............................. ............................. 27. Montana ........................................................................... MT .............................. .............................. .............................. ............................. 28. Nebraska .......................................................................... NE .............................. .............................. .............................. ............................. 29. Nevada ............................................................................. NV .............................. .............................. .............................. ............................. 30. New Hampshire ............................................................... NH .............................. .............................. .............................. ............................. 31. New Jersey ........................................................................ NJ .............................. .............................. .............................. ............................. 32. New Mexico.................................................................... NM .............................. .............................. .............................. ............................. 33. New York ......................................................................... NY .............................. .............................. .............................. ............................. 34. North Carolina ................................................................. NC .............................. .............................. .............................. ............................. 35. North Dakota .................................................................. ND .............................. .............................. .............................. ............................. 36. Ohio ................................................................................. OH .............................. .............................. .............................. ............................. 37. Oklahoma ......................................................................... OK .............................. .............................. .............................. ............................. 38. Oregon ............................................................................. OR .............................. .............................. .............................. ............................. 39. Pennsylvania .....................................................................PA .............................. .............................. .............................. ............................. 40. Rhode Island ...................................................................... RI .............................. .............................. .............................. ............................. 41. South Carolina .................................................................. SC .............................. .............................. .............................. ............................. 42. South Dakota ....................................................................SD .............................. .............................. .............................. ............................. 43. Tennessee ........................................................................ TN .............................. .............................. .............................. ............................. 44. Texas ................................................................................ TX .............................. .............................. .............................. ............................. 45. Utah .................................................................................. UT .............................. .............................. .............................. ............................. 46. Vermont ........................................................................... VT .............................. .............................. .............................. ............................. 47. Virginia ............................................................................ VA .............................. .............................. .............................. ............................. 48. Washington ..................................................................... WA .............................. .............................. .............................. ............................. 49. West Virginia .................................................................. WV .............................. .............................. .............................. ............................. 50. Wisconsin .........................................................................WI .............................. .............................. .............................. ............................. 51. Wyoming ........................................................................ WY .............................. .............................. .............................. ............................. 52. American Samoa ...............................................................AS .............................. .............................. .............................. ............................. 53. Guam ................................................................................ GU .............................. .............................. .............................. ............................. 54. Puerto Rico ....................................................................... PR .............................. .............................. .............................. ............................. 55. US Virgin Islands ............................................................. VI .............................. .............................. .............................. ............................. 56. Northern Mariana Islands ................................................ MP .............................. .............................. .............................. ............................. 57. Canada .......................................................................... CAN .............................. .............................. .............................. ............................. 58. Aggregate Other Alien .................................................... OT 59. Total

Attachment B


Part 4 – Other Private Passenger Auto Liability Annual Statement Line 19.2

1 2 3 4

Direct Premiums





Attachment B


Part 5 – Private Passenger Auto Physical Damage Annual Statement Line 21.1

1 2 3 4

Direct Premiums





Attachment B


SUPPLEMENTAL EXHIBITS AND SCHEDULES INTERROGATORIES

The following supplemental reports are required to be filed as part of your statement filing unless specifically waived by the domiciliary state. However, in the event that your domiciliary state waives the filing requirement, your response of WAIVED to the specific interrogatory will be accepted in lieu of filing a “NONE” report and a bar code will be printed below. If the supplement is required of your company but is not being filed for whatever reason, enter SEE EXPLANATION and provide an explanation following the interrogatory questions.

MARCH FILING RESPONSES

1. Will an actuarial opinion be filed by March 1? ....................................................

2. Will the Supplemental Compensation Exhibit be filed with the state of domicile by March 1? ....................................................

3. Will the confidential Risk-based Capital Report be filed with the NAIC by March 1? ....................................................

4. Will the confidential Risk-based Capital Report be filed with the state of domicile, if required, by March 1? ....................................................

APRIL FILING

5. Will the Insurance Expense Exhibit be filed with the state of domicile and the NAIC by April 1? ....................................................

6. Will Management’s Discussion and Analysis be filed by April 1? ....................................................

7. Will the Supplemental Investment Risks Interrogatories be filed by April 1? ....................................................

MAY FILING

8. Will this company be included in a combined annual statement that is filed with the NAIC by May 1? ....................................................

JUNE FILING

9. Will an audited financial report be filed by June 1? ....................................................

10. Will Accountants Letter of Qualifications be filed with the state of domicile and electronically with the NAIC by June 1? ....................................................

The following supplemental reports are required to be filed as part of your statement filing if your company is engaged in the type of business covered by the supplement. However, in the event that your company does not transact the type of business for which the special report must be filed, your response of NO to the specific interrogatory will be accepted in lieu of filing a “NONE” report and a bar code will be printed below. If the supplement is required of your company but is not being filed for whatever reason, enter SEE EXPLANATION and provide an explanation following the interrogatory questions.

MARCH FILING

11. Will Schedule SIS (Stockholder Information Supplement) be filed with the state of domicile by March 1? ............................................

12. Will the Financial Guaranty Insurance Exhibit be filed by March 1? ............................................

13. Will the Medicare Supplement Insurance Experience Exhibit be filed with the state of domicile and the NAIC by March 1? ............................................

14. Will Supplement A to Schedule T (Medical Professional Liability Supplement) be filed by March 1? ............................................

15. Will the Trusteed Surplus Statement be filed with the state of domicile and the NAIC by March 1? ............................................

16. Will the Premiums Attributed to Protected Cells Exhibit be filed by March 1? ............................................

17. Will the Reinsurance Summary Supplemental Filing for General Interrogatory 9 be filed with the state of domicile and the NAIC by March 1? ............................................

18. Will the Medicare Part D Coverage Supplement be filed with the state of domicile and the NAIC by March 1? ............................................

19. Will the confidential Actuarial Opinion Summary be filed with the state of domicile, if required, by March 15 (or the date otherwise specified)?

20. Will the Reinsurance Attestation Supplement be filed with the state of domicile and the NAIC by March 1?

21. Will the Exceptions to the Reinsurance Attestation Supplement be filed with the state of domicile by March 1?

............................................

............................................

............................................

22. Will the Bail Bond Supplement be filed with the state of domicile and the NAIC by March 1? ............................................

23. Will the Director and Officer Insurance Coverage Supplement be filed with the state of domicile and the NAIC by March 1? ............................................

24. Will an approval from the reporting entity’s state of domicile for relief related to the five-year rotation requirement for lead audit partner be filed

electronically with the NAIC by March 1?

............................................

25. Will an approval from the reporting entity’s state of domicile for relief related to the one-year cooling off period for independent CPA be filed


............................................

26. Will an approval from the reporting entity’s state of domicile for relief related to the Requirements for Audit Committees be filed electronically

with the NAIC by March 1?

............................................

27. Will the Supplemental Schedule for Reinsurance Counterparty Reporting Exception – Asbestos and Pollution contracts be filed with the state of domicile and the NAIC by March 1?

............................................

28. Will the Direct Premium and Exposures Supplement be filed with NAIC by March 1? ............................................

APRIL FILING

2829. Will the Credit Insurance Experience Exhibit be filed with the state of domicile and the NAIC by April 1? ............................................

2930. Will the Long-term Care Experience Reporting Forms be filed with the state of domicile and the NAIC by April 1? ............................................

3031. Will the Accident and Health Policy Experience Exhibit be filed by April 1? ............................................

3132. Will the Supplemental Health Care Exhibit (Parts 1, 2 and 3) be filed with the state of domicile and the NAIC by April 1? ............................................

3233. Will the regulator-only (non-public) Supplemental Health Care Exhibit’s Allocation Report be filed with the state of domicile and the NAIC by April 1? ............................................

3334. Will the Cybersecurity and Identity Theft Insurance Coverage Supplement be filed with the state of domicile and the NAIC by April 1? ............................................

34.35. Will the Life, Health & Annuity Guaranty Association Assessable Premium Exhibit – Parts 1 and 2 be filed with the state of domicile and the NAIC by April 1? ............................................

3536. Will the Private Flood Insurance Supplement be filed with the state of domicile and the NAIC by April 1? ............................................

AUGUST FILING

3637. Will Management’s Report of Internal Control Over Financial Reporting be filed with the state of domicile by August 1? ............................................

Explanation: Bar Code:

Attachment B


QUARTERLY STATEMENT BLANK – PROPERTY

PART 1 – LOSS EXPERIENCE

Current Year to Date 45 1 2 23 34 Prior Year to Date

Line of Business Direct Premiums

Earned Direct Earned

Exposures Direct Losses

Incurred Direct Loss Percentage

Direct Loss Percentage

1. Fire .............................................................................................. ..................................... XXX ..................................... ..................................... .................................. 2.1 Allied Lines ................................................................................. ..................................... XXX ..................................... ..................................... .................................. 2.2 Multiple Peril Crop ..................................................................... ..................................... XXX ..................................... ..................................... .................................. 2.3 Federal Flood .............................................................................. ..................................... XXX ..................................... ..................................... .................................. 2.4 Private Crop ................................................................................ ..................................... XXX ..................................... ..................................... .................................. 2.5 Private Flood ............................................................................... ..................................... XXX ..................................... ..................................... .................................. 3. Farmowners Multiple Peril ......................................................... ..................................... XXX ..................................... ..................................... .................................. 4. Homeowners Multiple Peril ........................................................ ..................................... ..................................... ..................................... ..................................... .................................. 5.1 Commercial Multiple Peril (Non-Liability Portion) ................... ..................................... XXX ..................................... ..................................... .................................. 5.2 Commercial Multiple Peril (Liability Portion) ........................... ..................................... XXX ..................................... ..................................... .................................. 6. Mortgage Guaranty ..................................................................... ..................................... XXX ..................................... ..................................... .................................. 8. Ocean Marine .............................................................................. ..................................... XXX ..................................... ..................................... .................................. 9. Inland Marine .............................................................................. ..................................... XXX ..................................... ..................................... .................................. 10. Financial Guaranty ...................................................................... ..................................... XXX ..................................... ..................................... .................................. 11.1 Medical Professional Liability—Occurrence .............................. ..................................... XXX ..................................... ..................................... .................................. 11.2 Medical Professional Liability—Claims-Made .......................... ..................................... XXX ..................................... ..................................... .................................. 12. Earthquake ................................................................................... ..................................... XXX ..................................... ..................................... .................................. 13.1 Comprehensive Individual Accident and Health ........................ ..................................... XXX ..................................... ..................................... .................................. 13.2 Comprehensive Group Accident and Health ............................... ..................................... XXX ..................................... ..................................... .................................. 14. Credit A&H (Group and Individual) ........................................... ..................................... XXX ..................................... ..................................... .................................. 15.1 Vision Only ................................................................................. ..................................... XXX ..................................... ..................................... .................................. 15.2 Dental Only ................................................................................. ..................................... XXX ..................................... ..................................... .................................. 15.3 Disability Income ........................................................................ ..................................... XXX ..................................... ..................................... .................................. 15.4 Medicare Supplement .................................................................. ..................................... XXX ..................................... ..................................... .................................. 15.5 Medicaid Title XIX ..................................................................... ..................................... XXX ..................................... ..................................... .................................. 15.6 Medicare Title XVIII Exempt from State Taxes or Fees ............ ..................................... XXX ..................................... ..................................... .................................. 15.7 Long-Term Care .......................................................................... ..................................... XXX ..................................... ..................................... .................................. 15.8 Federal Employees Health Benefits Plan Premium .................... ..................................... XXX ..................................... ..................................... .................................. 15.9 Other Health ................................................................................ ..................................... XXX ..................................... ..................................... .................................. 16. Workers’ Compensation .............................................................. ..................................... XXX ..................................... ..................................... .................................. 17.1 Other Liability—Occurrence ...................................................... ..................................... XXX ..................................... ..................................... .................................. 17.2 Other Liability—Claims-Made ................................................... ..................................... XXX ..................................... ..................................... .................................. 17.3 Excess Workers’ Compensation ................................................. ..................................... XXX ..................................... ..................................... .................................. 18.1 Products Liability—Occurrence .................................................. ..................................... XXX ..................................... ..................................... .................................. 18.2 Products Liability—Claims-Made .............................................. ..................................... XXX ..................................... ..................................... .................................. 19.1 Private Passenger Auto No-Fault (Personal Injury Protection) .. ..................................... ..................................... ..................................... ..................................... .................................. 19.2 Other Private Passenger Auto Liability ....................................... ..................................... ..................................... ..................................... ..................................... .................................. 19.3 Commercial Auto No-Fault (Personal Injury Protection) ........... ..................................... XXX ..................................... ..................................... .................................. 19.4 Other Commercial Auto Liability ............................................... ..................................... XXX ..................................... ..................................... .................................. 21.1 Private Passenger Auto Physical Damage ................................... ..................................... ..................................... ..................................... ..................................... .................................. 21.2 Commercial Auto Physical Damage ........................................... ..................................... XXX ..................................... ..................................... .................................. 22. Aircraft (all perils) ....................................................................... ..................................... XXX ..................................... ..................................... .................................. 23. Fidelity ........................................................................................ ..................................... XXX ..................................... ..................................... .................................. 24. Surety .......................................................................................... ..................................... XXX ..................................... ..................................... .................................. 26. Burglary and Theft ...................................................................... ..................................... XXX ..................................... ..................................... .................................. 27. Boiler and Machinery .................................................................. ..................................... XXX ..................................... ..................................... .................................. 28. Credit ........................................................................................... ..................................... XXX ..................................... ..................................... .................................. 29. International ................................................................................ ..................................... XXX ..................................... ..................................... .................................. 30. Warranty ...................................................................................... ..................................... XXX ..................................... ..................................... .................................. 31. Reinsurance-Nonproportional Assumed Property ...................... XXX XXX XXX XXX XXX 32. Reinsurance-Nonproportional Assumed Liability ...................... XXX XXX XXX XXX XXX 33. Reinsurance-Nonproportional Assumed Financial Lines ........... XXX XXX XXX XXX XXX 34. Aggregate Write-Ins for Other Lines of Business ....................... XXX 35. TOTALS XXX

DETAILS OF WRITE-INS 3401. ..................................................................................................... ..................................... XXX ..................................... ..................................... ..................................3402. ..................................................................................................... ..................................... XXX ..................................... ..................................... ..................................3403. ..................................................................................................... ..................................... XXX ..................................... ..................................... ..................................3498. Sum. of remaining write-ins for .... Line 34 from overflow page ..................................... XXX ..................................... ..................................... ..................................3499. Totals (Lines 3401 through 3403 plus 3498) (Line 34 above) XXX

Attachment B


PART 2 – DIRECT PREMIUMS WRITTEN

Current Quarter 23 34 1 2 Current Year to Date

Line of Business Direct Premiums Written Direct Written Exposures Direct Premiums Written Prior Year to Date 1. Fire .............................................................................................. ............................................ XXX ............................................ ............................................ 2.1 Allied Lines ................................................................................. ............................................ XXX ............................................ ............................................ 2.2 Multiple Peril Crop ..................................................................... ............................................ XXX ............................................ ............................................ 2.3 Federal Flood .............................................................................. ............................................ XXX ............................................ ............................................ 2.4 Private Crop ................................................................................ ............................................ XXX ............................................ ............................................ 2.5 Private Flood ............................................................................... ............................................ XXX ............................................ ............................................ 3. Farmowners Multiple Peril ......................................................... ............................................ XXX ............................................ ............................................ 4. Homeowners Multiple Peril ........................................................ ............................................ ................................................. ............................................ ............................................ 5.1 Commercial Multiple Peril (Non-Liability Portion) ................... ............................................ XXX ............................................ ............................................ 5.2 Commercial Multiple Peril (Liability Portion) ........................... ............................................ XXX ............................................ ............................................ 6. Mortgage Guaranty ..................................................................... ............................................ XXX ............................................ ............................................ 8. Ocean Marine .............................................................................. ............................................ XXX ............................................ ............................................ 9. Inland Marine .............................................................................. ............................................ XXX ............................................ ............................................ 10. Financial Guaranty ...................................................................... ............................................ XXX ............................................ ............................................ 11.1 Medical Professional Liability—Occurrence .............................. ............................................ XXX ............................................ ............................................ 11.2 Medical Professional Liability—Claims-Made .......................... ............................................ XXX ............................................ ............................................ 12. Earthquake ................................................................................... ............................................ XXX ............................................ ............................................ 13.1 Comprehensive Individual Accident and Health ........................ ............................................ XXX ............................................ ............................................ 13.2 Comprehensive Group Accident and Health ............................... ............................................ XXX ............................................ ............................................ 14. Credit A&H (Group and Individual) ........................................... ............................................ XXX ............................................ ............................................ 15.1 Vision Only ................................................................................. ............................................ XXX ............................................ ............................................ 15.2 Dental Only ................................................................................. ............................................ XXX ............................................ ............................................ 15.3 Disability Income ........................................................................ ............................................ XXX ............................................ ............................................ 15.4 Medicare Supplement .................................................................. ............................................ XXX ............................................ ............................................ 15.5 Medicaid Title XIX ..................................................................... ............................................ XXX ............................................ ............................................ 15.6 Medicare Title XVIII Exempt from State Taxes or Fees ............ ............................................ XXX ............................................ ............................................ 15.7 Long-Term Care .......................................................................... ............................................ XXX ............................................ ............................................ 15.8 Federal Employees Health Benefits Plan Premium .................... ............................................ XXX ............................................ ............................................ 15.9 Other Health ................................................................................ ............................................ XXX ............................................ ............................................ 16. Workers’ Compensation .............................................................. ............................................ XXX ............................................ ............................................ 17.1 Other Liability—Occurrence ...................................................... ............................................ XXX ............................................ ............................................ 17.2 Other Liability—Claims-Made ................................................... ............................................ XXX ............................................ ............................................ 17.3 Excess Workers’ Compensation ................................................. ............................................ XXX ............................................ ............................................ 18.1 Products Liability—Occurrence .................................................. ............................................ XXX ............................................ ............................................ 18.2 Products Liability—Claims-Made .............................................. ............................................ XXX ............................................ ............................................ 19.1 Private Passenger Auto No-Fault (Personal Injury Protection) .. ............................................ ................................................. ............................................ ............................................ 19.2 Other Private Passenger Auto Liability ....................................... ............................................ ................................................. ............................................ ............................................ 19.3 Commercial Auto No-Fault (Personal Injury Protection) ........... ............................................ XXX ............................................ ............................................ 19.4 Other Commercial Auto Liability ............................................... ............................................ XXX ............................................ ............................................ 21.1 Private Passenger Auto Physical Damage ................................... ............................................ ................................................. ............................................ ............................................ 21.2 Commercial Auto Physical Damage ........................................... ............................................ XXX ............................................ ............................................ 22. Aircraft (all perils) ....................................................................... ............................................ XXX ............................................ ............................................ 23. Fidelity ........................................................................................ ............................................ XXX ............................................ ............................................ 24. Surety .......................................................................................... ............................................ XXX ............................................ ............................................ 26. Burglary and Theft ...................................................................... ............................................ XXX ............................................ ............................................ 27. Boiler and Machinery .................................................................. ............................................ XXX ............................................ ............................................ 28. Credit ........................................................................................... ............................................ XXX ............................................ ............................................ 29. International ................................................................................ ............................................ XXX ............................................ ............................................ 30. Warranty ...................................................................................... ............................................ XXX ............................................ ............................................ 31. Reinsurance-Nonproportional Assumed Property ...................... XXX XXX XXX XXX 32. Reinsurance-Nonproportional Assumed Liability ...................... XXX XXX XXX XXX 33. Reinsurance-Nonproportional Assumed Financial Lines ........... XXX XXX XXX XXX 34. Aggregate Write-Ins for Other Lines of Business ....................... XXX 35. TOTALS XXX

DETAILS OF WRITE-INS 3401. ..................................................................................................... ............................................ XXX ............................................ ............................................3402. ..................................................................................................... ............................................ XXX ............................................ ............................................3403. ..................................................................................................... ............................................ XXX ............................................ ............................................3498. Sum. of remaining write-ins for .... Line 34 from overflow page ............................................ XXX ............................................ ............................................3499. Totals (Lines 3401 through 3403 plus 3498) (Line 34 above) XXX

W:\QA\BlanksProposals\2021-11BWG_Modiied.doc

Attachment C




DATE: 04/15/2021

CONTACT PERSON:

TELEPHONE:

EMAIL ADDRESS: ON BEHALF OF:

NAME: Steve Drutz

TITLE: Chief Financial Analyst

AFFILIATION: WA Office of the Insurance Commissioner

ADDRESS:




DISPOSITION [ ] Rejected For Public Comment [ ] Referred To Another NAIC Group [ ] Received For Public Comment [ ] Adopted Date [ ] Rejected Date [ X ] Deferred Date 07/22/2021 [ ] Other (Specify)


[ X ] ANNUAL STATEMENT [ X ] INSTRUCTIONS [ X ] CROSSCHECKS [ ] QUARTERLY STATEMENT [ X ] BLANK

[ X ] Life, Accident & Health/Fraternal [ ] Separate Accounts [ ] Title [ ] Property/Casualty [ ] Protected Cell [ ] Other _______________________ [ ] Health [ ] Health (Life Supplement)


IDENTIFICATION OF ITEM(S) TO CHANGE Add and delete lines on the Analysis of Operations by Lines of Business – Accident and Health for Life\Fraternal to capture health specific data captured on the Heath Analysis of Operations by Lines of Business but not on the Life\Fraternal Analysis of Operations page and add new crosschecks for the new lines. Add new crosschecks to the Analysis of Operations by Lines of Business – Summary to map the lines on the accident and health page to the summary.

REASON, JUSTIFICATION FOR AND/OR BENEFIT OF CHANGE** The purpose of the proposal is to modify the Analysis of Operations by Lines of Business – Accident and Health for Life\Fraternal to capture health specific data points captured on the Health Analysis of Operations page. This will allow regulators to look at revenue and expenses in the same detail as reported on the Heath Analysis of Operations by Lines of Business.


Attachment C


ANNUAL STATEMENT INSTRUCTIONS – LIFE\FRATERNAL

ANALYSIS OF OPERATIONS BY LINES OF BUSINESS – ACCIDENT AND HEALTH This exhibit shows Lines 1 through 33 of the Summary of Operations by Line of Business, in part. For definitions of lines of business, see the appendix of these instructions.

Detail Eliminated to Conserve Space

Line 1.1 – Net Premium Income

Written premium is defined as the contractually determined amount charged by the reporting entity to the policyholder for the effective period of the contract based on the expectation of risk, policy benefits, and expenses associated with the coverage provided by the terms of the insurance contract. For health contracts without fixed contract periods, premiums written will be equal to the amount collected during the reporting period plus uncollected premiums at the end of the period less uncollected premiums at the beginning of the period.

Include: Accrued return premium adjustments for contracts subject to redetermination.

Line 1.2 – Change in Unearned Premium Reserves and Reserve for Rate Credits

Exclude: Reserves relating to uninsured plans and the uninsured portion of partially insured plans.

Line 1.3 – Fee-for-Service (Net of $____ Medical Expenses)

Include: Revenue recognized by the reporting entity for provision of health services to non-members by reporting entity providers and to members through provision of health services excluded from their prepaid benefit packages. Include in the inside amount, the medical expenses associated with fee-for-service business.

Line 1.4 – Risk Revenue

Include: Amounts charged by the reporting entity as a provider or intermediary for specified medical services (e.g., full professional, dental, radiology, etc.) provided to the policyholders or members of another insurer or reporting entity.

Unlike premiums that are collected from an employer group or individual member, risk revenue is the prepaid (usually on a capitated basis) payment, made by another insurer or reporting entity to the reporting entity in exchange for services to be provided or offered by such organization.

Line 1.5 – Other Health Care Related Revenues

Include: Revenue from sources not covered in the other revenue accounts. Line 1.6 – Premiums for Accident and Health Contracts (Lines 1.1 to 1.5)

Column 1 should equal the total premiums reported in Exhibit, Part 1, Line 20.4, sum of Columns 8, 9, and 10.

Attachment C


Line 43 – Amortization of the Interest Maintenance Reserve

Report the amount shown on Page 4, Line 4, in part, and on Page 28, Line 5, in part.

Allocate the amortization of the Interest Maintenance Reserve in the same manner that investment income would have been allocated had the investment not been sold.

Line 54 – Separate Accounts Net Gain from Operations Excluding Unrealized Gains or Losses

Report the total net gain from operations shown on Page 4 of the Separate Accounts Statement, in part, excluding the portion due to unrealized capital gains or losses.

Line 8.17.1 – Fees associated with Income from Investment Management, Administration and Contract Guarantees

from Separate Accounts

Include: Gross amount of fees and charges from separate accounts. Line 8.37.2 – Aggregate Write-Ins for Miscellaneous Income

Enter the total of the write-ins listed in schedule Details of Write-ins Aggregated at Line 8.37.2 for Miscellaneous Income.

Line 9.1 – Hospital/Medical Benefits

Include: Expenses for physician services provided under contractual arrangement to the reporting entity.

Salaries, including fringe benefits, paid to physicians for delivery of medical services. Capitation payments by the reporting entity to physicians for delivery of medical services to reporting entity subscribers.

Fees paid by the reporting entity to physicians on a fee-for-service basis for delivery of medical services to reporting entity subscribers. This includes capitated referrals.

Inpatient hospital costs of routine and ancillary services for reporting entity members while confined to an acute care hospital.

Charges for non-reporting entity physician services provided in a hospital are included in this line item only if included as an undefined portion of charges by a hospital to the reporting entity. (If separately itemized or billed, physician charges should be included in outside referrals below.)

The cost of utilizing skilled nursing and intermediate care facilities.

Routine hospital service includes regular room and board (including intensive care units, coronary care units, and other special inpatient hospital units), dietary and nursing services, medical surgical supplies, medical social services, and the use of certain equipment and facilities for which the provider does not customarily make a separate charge.

Attachment C


Ancillary services may also include laboratory, radiology, drugs, delivery room, physical therapy services, other special items and services for which charges are customarily made in addition to a routine service charge.

Skilled nursing facilities are primarily engaged in providing skilled nursing care and related services for patients who require medical or nursing care or rehabilitation service.

Intermediate care facilities are for individuals who do not require the degree of care and treatment that a hospital or skilled nursing-care facility provides, but that do require care and services above the level of room and board.

Report gross of reinsurance. Report net of coordination of benefits, co-payments and subrogation.

Exclude: Expenses for medical personnel time devoted to administrative tasks.

Emergency room and out-of-area hospitalization.

All items meeting the definition of Cost Containment Expenses found in SSAP No. 55—Unpaid Claims, Losses and Loss Adjustment Expenses.

Line 9.2 – Other Professional Services

Include: Expenses for other professional providers under contractual arrangement to the reporting entity.

Salaries, as well as fringe benefits, paid by the reporting entity to non-physician providers licensed, accredited or certified to perform specified health services, consistent with state law, engaged in the delivery of medical services.

Compensation to personnel engaged in activities in direct support of the provision of medical services. For example, include compensation to pharmacists, dentists, psychologists, optometrists, podiatrists, extenders, nurses, clinical personnel such as ambulance drivers and technicians.

Exclude: Professional services not meeting this definition. Report these services

as administrative expenses. For example, exclude compensation to paraprofessionals, janitors, quality assurance analysts, administrative supervisors, secretaries to medical personnel, and medical record clerks.

Prescription drugs.


Line 9.3 – Outside Referrals

Include: Expenses for providers not under arrangement with the reporting entity to provide services, such as consultations, or out-of-network providers.

Attachment C


Line 9.4 – Emergency Room and Out-of-Area

Include: Expenses for other health delivery services including emergency room costs incurred by members for which the reporting entity is responsible and out-of-area service costs for emergency physician and hospital.

In the event a member is admitted to the health care facility immediately after seeking emergency room service, emergency service expenses are reported in this line, the expenses after admission are reported in the hospital/medical line, provided the member is seeking services in the service area. Out-of-area expenses incurred, whether emergency or hospital, are reported in this line.

Line 9.5 – Prescription Drugs

Include: Expenses for Prescription Drugs and other pharmacy benefits covered by the reporting entity.

Deduct: Pharmaceutical rebates relating to insured plans.

Exclude: Prescription drug charges that are included in a hospital billing which should be

classified as Hospital/Medical Benefits on Line 9.1. Line 9.6 – Other Hospital and Medical

Include: Other hospital and medical expenses not covered in the other claims accounts. Line 9.7 – Incentive Pool, Withhold Adjustments and Bonus Amounts

This category is for adjusting the full medical expenses reported by means of both debit and credit entries. For example, report physician withholds forfeited to the reporting entity as a credit entry. Report amounts incurred due to an arrangement whereby the reporting entity agrees to utilization savings with a provider as a debit entry.

Line 10 – Net Reinsurance Recoveries

Amounts recovered and recoverable from reinsurers on paid losses

Include: Amounts related to assumed and ceded business. Line 1613 – Group Conversions

Include: The customary charges, in the appropriate columns, to cover the excess cost arising from group conversions.

This line is not applicable to Fraternal Benefit Societies.

Line 2117 – Commissions on Premiums (Direct Business Only)

Column1 should agree with Exhibit 1 Part 2, Line 31, Columns 8, 9 and 10.

Attachment C


Line 19.1 – Claims Adjustment Expenses, Including $___ Cost Containment Expenses

All expenses incurred in connection with the recording, adjustment and settlement of claims. This includes the total of the expense classification “Other Claim Adjustment Expenses” and all “Cost Containment Expenses”.

Cost Containment Expenses and Other Claim Adjustment Expenses have been defined in SSAP No. 55—Unpaid Claims, Losses and Loss Adjustment Expenses. Refer to SSAP No. 55 for accounting guidance.

The inset amount should equal Column 2, Line 10, Exhibit 2.

Line 19.2 – General Administrative Expenses

Exclude: All expenses related to cost containment activities in accordance with SSAP No. 55—Unpaid Claims, Losses and Loss Adjustment Expenses.

Insurance taxes, licenses and fees, excluding federal income taxes included on Line 20.

Line 19.3 – Total General Insurance Expenses (Line 19.1 plus 19.2)

Column 1 should equal Exhibit 2, Line 10 sum of Columns 2 and 3. Line 20 – Insurance Taxes, Licenses and Fees, Excluding Federal Income Taxes

Column 1 should equal Exhibit 3, Column 2, Line 7. Line 2723 – Aggregate Write-ins for Deductions

Enter the total of the write-ins listed in schedule Details of Write-ins Aggregated at Line 27 23 for Deductions.

Details of Write-ins Aggregated at Line 8.37.2 for Miscellaneous Income.

List separately each category of miscellaneous income for which there is no pre-printed line on Analysis of Operations by Lines of Business – Accident and Health.

Details of Write-ins Aggregated at Line 27 23 for Deductions

List separately each category of deductions for which there is no pre-printed line on Analysis of Operations by Lines of Business – Accident and Health.

Include: The amount from the Form for Calculating the Interest Maintenance Reserve,

Line 3, in part.

Attachment C


ANALYSIS OF OPERATIONS BY LINES OF BUSINESS – SUMMARY


Column 6 – Accident and Health

The lines in this column should equal the Analysis of Operations by Lines of Business – Accident and Health, Column 1.

Line 1: Should equal Analysis of Operations by Lines of Business – Accident and Health,

Column 1, Line 1.6.

Line 3: Should equal Analysis of Operations by Lines of Business – Accident and Health, Column 1, Line 2.


Column 1, Line 3.



Column 1, Line 5.


Line 8.1: Should equal Analysis of Operations by Lines of Business – Accident and Health,

Column 1, Line 7.1.

Line 8.3: Should equal Analysis of Operations by Lines of Business – Accident and Health, Column 1, Line 7.2.


Column 1, Line 8.



Column 1, Line 12.



Column 1, Line 14.

Line 19: Should equal Analysis of Operations by Lines of Business – Accident and Health, Column 1, Line 15


Column 1, Line 16.


Attachment C




Column 1, Line 19.3.



Column 1, Line 21.



Column 1, Line 23.


Line 29 Should equal Analysis of Operations by Lines of Business – Accident and Health,

Column 1, Line 25.

Line 30 Should equal Analysis of Operations by Lines of Business – Accident and Health, Column 1, Line 26.


Column 1, Line 27.



Column 1, Line 29.



Attachment C


ANNUAL STATEMENT BLANK – LIFE\FRATERNAL

ANALYSIS OF OPERATIONS BY LINES OF BUSINESS – ACCIDENT AND HEALTH (a)

1 Comprehensive 4 5 6 7 8 9 10 11 12 13

Total

2

Individual

3

Group Medicare

Supplement Vision Only

Dental Only

Federal Employees

Health Benefits

Plan

Title XVIII

Medicare Title XIX Medicaid

Credit A&H

Disability Income

Long-Term Care

Other Health

1. Premiums for accident and health contracts ............................................................... ................. ................. ................. ................. ................. ................. .................... ................. ................. ................. ................. ................. ................. 2. Considerations for supplementary contracts with life contingencies ......................... XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 3. Net investment income ............................................................................................... ................. ................. ................. ................. ................. .................. .................... ................. ................. ................. ................. ................. ................. 4. Amortization of Interest Maintenance Reserve (IMR) ............................................... ................. ................. ................. ................. ................. .................. .................... ................. ................. ................. ................. ................. ................. 5. Separate Accounts net gain from operations excluding unrealized gains or losses ................. ................. ................. ................. ................. .................. .................... ................. ................. ................. ................. ................. ................. 6. Commissions and expense allowances on reinsurance ceded .................................... ................. ................. ................. ................. ................. ................. .................... ................. ................. ................. ................. ................. ................. 7. Reserve adjustments on reinsurance ceded ................................................................. ................. ................. ................. ................. ................. ................. .................... ................. ................. ................. ................. ................. ................. 8. Miscellaneous Income: 8.1 Income from fees associated with investment management,

administration and contract guarantees from Separate Accounts .................. ................. ................. ................. ................. ................. .................. .................... ................. ................. ................. ................. ................. ................. 8.2 Charges and fees for deposit-type contracts................................................... XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 8.3 Aggregate write-ins for miscellaneous income .............................................. 9. Totals (Lines 1 to 8.3) ................................................................................................. 10. Death benefits ............................................................................................................. XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 11. Matured endowments (excluding guaranteed annual pure endowments) ................... XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 12. Annuity benefits .......................................................................................................... XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Disability benefits and benefits under accident and health contracts ......................... ................. ................. .............. .............. .............. ................ .................... ................. ................. .................... .............. .............. .............. 14. Coupons, guaranteed annual pure endowments and similar benefits ......................... ................. ................. .............. .............. .............. ................ .................... ................. ................. .................... .............. .............. .............. 15. Surrender benefits and withdrawals for life contracts ................................................ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. Group conversions ...................................................................................................... ................. ................. .............. .............. .............. ................ .................... ................. ................. .................... .............. .............. .............. 17. Interest and adjustments on contract or deposit-type contract funds .......................... ................. ................. .............. .............. .............. ................ .................... ................. ................. .................... .............. .............. .............. 18. Payments on supplementary contracts with life contingencies .................................. XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 19. Increase in aggregate reserves for life and accident and health contracts .................. 20. Totals (Lines 10 to 19) ................................................................................................ ................. ................. ................. ................. ................. .................. .................... ................. ................. ................. ................. ................. ................. 21. Commissions on premiums, annuity considerations and deposit-type contract

funds (direct business only) ........................................................................................ ................. ................. ................. ................. ................. .................. .................... ................. ................. ................. ................. ................. ................. 22. Commissions and expense allowances on reinsurance assumed ................................ ................. ................. ................. ................. ................. .................. .................... ................. ................. ................. ................. ................. ................. 23. General insurance expenses ........................................................................................ ................. ................. ................. ................. ................. .................. .................... ................. ................. ................. ................. ................. ................. 24. Insurance taxes, licenses and fees, excluding federal income taxes ........................... ................. ................. ................. ................. ................. .................. .................... ................. ................. ................. ................. ................. ................. 25. Increase in loading on deferred and uncollected premiums ....................................... ................. ................. ................. ................. ................. .................. .................... ................. ................. ................. ................. ................. ................. 26. Net transfers to or (from) Separate Accounts net of reinsurance ............................... ................. ................. ................. ................. ................. .................. .................... ................. ................. ................. ................. ................. ................. 27. Aggregate write-ins for deductions ............................................................................. 28. Totals (Lines 20 to 27) ................................................................................................ ................. ................. ................. ................. ................. .................. .................... ................. ................. ................. ................. ................. ................. 29. Net gain from operations before dividends to policyholders, and refunds to

members and federal income taxes (Line 9 minus Line 28) ....................................... ................. ................. ................. ................. ................. .................. .................... ................. ................. ................. ................. ................. ................. 30. Dividends to policyholders and refunds to members .................................................. ................. ................. ................. ................. ................. .................. .................... ................. ................. ................. ................. ................. ................. 31. Net gain from operations after dividends to policyholders, refunds to members

and before federal income taxes (Line 29 minus Line 30) ......................................... 32. Federal income taxes incurred (excluding tax on capital gains) ................................. 33. Net gain from operations after dividends to policyholders, refunds to members

and federal income taxes and before realized capital gains or (losses) (Line 31 minus Line 32)

34. Policies/certificates in force end of year

DETAILS OF WRITE-INS 08.301. ................................................................................................................................08.302. ................................................................................................................................08.303. ................................................................................................................................08.398. Summary of remaining write-ins for Line 8.3 from overflow page ......................08.399. Total (Lines 08.301 through 08.303 plus 08.398) (Line 8.3 above)

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2701. ................................................................................................................................2702. ................................................................................................................................2703. ................................................................................................................................2798. Summary of remaining write-ins for Line 27 from overflow page ........................2799. Total (Lines 2701 through 2703 plus 2798) (Line 27 above)

................. ................. ................. .................

................. ................. ................. .................

................. ................. ................. .................

................. ................. ................. .................

................. ................. ................. .................

................. ................. ................. .................

.................... .................... .................... ....................

................. ................. ................. .................

................. ................. ................. .................

................. ................. ................. .................

................. ................. ................. .................

................. ................. ................. .................

................. ................. ................. .................

(a) Indicate if blocks of business in run-off that comprise less than 5% of premiums and less than 5% of reserve and loans liability are aggregated with material blocks of business and which columns are affected. ...................................

Attachment C


ANALYSIS OF OPERATIONS BY LINES OF BUSINESS – ACCIDENT AND HEALTH (a)

1 Comprehensive 4 5 6 7 8 9 10 11 12 13

Total

2

Individual

3

Group Medicare

Supplement Vision Only Dental Only

Federal Employees

Health Benefits

Plan Title XVIII Medicare

Title XIX Medicaid Credit A&H

Disability Income

Long-Term Care

Other Health

1. Premiums for accident and health contracts 1.1 Net premium income............................................................................................................. 1.2 Change in unearned premium reserves and reserve for rate credit ....................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 1.3 Fee-for-service (net of $......... medical expenses) ................................................................ .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 1.4 Risk revenue ......................................................................................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 1.5 Other health care related revenues ........................................................................................ .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 1.6 Premiums for accident and health contracts (Lines 1.1 to 1.5) ............................................. .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 2. Net investment income ........................................................................................................................ .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 3. Amortization of Interest Maintenance Reserve (IMR)......................................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 4. Separate Accounts net gain from operations excluding unrealized gains or losses .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 5. Commissions and expense allowances on reinsurance ceded .............................................................. .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 6. Reserve adjustments on reinsurance ceded .......................................................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 7. Miscellaneous Income: 7.1 Income from fees associated with investment management, administration and contract

guarantees from Separate Accounts ...................................................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 7.2 Aggregate write-ins for miscellaneous income ..................................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 8. Totals (Lines 1.6 + 2+ 3 + 4 + 5+ 6 + 7.1 + 7.2).................................................................................. .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 9. Hospital and Medical 9.1 Hospital/medical benefits ...................................................................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 9.2 Other professional services ................................................................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 9.3 Outside referrals .................................................................................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 9.4 Emergency room and out-of-area ......................................................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 9.5 Prescription drugs ................................................................................................................. .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 9.6 Other hospital and medical ................................................................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 9.7 Incentive pool, withhold adjustments and bonus amounts .................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 9.8 Subtotal Hospital and Medical (Lines 9.1 to 9.7) ................................................................. .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 10. Net reinsurance recoveries ................................................................................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 11. Total hospital and medical (Lines 9.8 minus 10) ................................................................................. .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 12. Coupons, guaranteed annual pure endowments and similar benefits ................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 13. Group conversions ............................................................................................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 14. Interest and adjustments on contract or deposit-type contract funds ................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 15. Increase in aggregate reserves for life and accident and health contracts ............................................ .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 16. Totals (Lines 11 to 15) ......................................................................................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 17. Commissions on premiums, annuity considerations and deposit-type contract funds (direct

business only) ...................................................................................................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 18. Commissions and expense allowances on reinsurance assumed .......................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 19. General insurance expenses ................................................................................................................. .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 19.1 Claims adjustment expenses including $………. cost containment expenses ...................... 19.2 General expenses .................................................................................................................. 19.3 Total general insurance expenses (Line 19.1 plus 19.2) ....................................................... 20. Insurance taxes, licenses and fees, excluding federal income taxes ..................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 21. Increase in loading on deferred and uncollected premiums ................................................................. .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 22. Net transfers to or (from) Separate Accounts net of reinsurance ......................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 23. Aggregate write-ins for deductions ...................................................................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 24. Totals (Lines 16 + 17 + 18 + 19.3 + 20 + 21 + 22 + 23) ...................................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 25. Net gain from operations before dividends to policyholders, and refunds to members and federal

income taxes (Line 8 minus Line 24)................................................................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 26. Dividends to policyholders and refunds to members ........................................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 27. Net gain from operations after dividends to policyholders, refunds to members and before

federal income taxes (Line 25 minus Line 26) ..................................................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 28. Federal income taxes incurred (excluding tax on capital gains) .......................................................... .................... ..................... .................... ..................... .................... ..................... .................... .................... ..................... .................... ..................... .................... ..................... 29. Net gain from operations after dividends to policyholders, refunds to members and federal

income taxes and before realized capital gains or (losses) (Line 27 minus Line 28)

30. Policies/certificates in force end of year

DETAILS OF WRITE-INS 07.201. ..................................................................................................................................................... 07.202. ..................................................................................................................................................... 07.203. ..................................................................................................................................................... 07.298. Summary of remaining write-ins for Line 7.2 from overflow page ............................................ 07.299. Total (Lines 07.201 through 07.203 plus 07.298) (Line 7.2 above)

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..................... ..................... ..................... .....................

.................... .................... .................... ....................

..................... ..................... ..................... .....................

2301. ........................................................................................................................................................ 2302. ........................................................................................................................................................ 2303. ........................................................................................................................................................ 2398. Summary of remaining write-ins for Line 23 from overflow page ................................................ 2399. Total (Lines 2301 through 2303 plus 2398) (Line 23 above)

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(a) Indicate if blocks of business in run-off that comprise less than 5% of premiums and less than 5% of reserve and loans liability are aggregated with material blocks of business and which columns are affected. ...................................

W:\QA\BlanksProposals\2021-12BWG.doc

Attachment D




DATE: 04/15/2021

CONTACT PERSON:

TELEPHONE:


NAME: Patricia Gosselin

TITLE:

AFFILIATION: New Hampshire Insurance Department

ADDRESS: 215 S. Fruit St., Ste. 14

Concord, NH 03301







[ ] Life, Accident & Health/Fraternal [ ] Separate Accounts [ ] Title [ X ] Property/Casualty [ ] Protected Cell [ ] Other _______________________ [ ] Health [ ] Health (Life Supplement)


IDENTIFICATION OF ITEM(S) TO CHANGE Add a new supplement to capture premium and loss data for Annual Statement Lines 17.1, 17.2 & 17.3 of the Exhibit of Premiums and Losses (State Page) – Other Liability by more granular lines of business.

REASON, JUSTIFICATION FOR AND/OR BENEFIT OF CHANGE** The purpose of this proposal is to provide regulators more granular detail of the premium and losses of the diverse lines of business reported on Annual Statement Lines 17.1, 17.2 & 17.3 of the Exhibit of Premiums and Losses (State Page).


Attachment D


ANNUAL STATEMENT INSTRUCTIONS – PROPERTY

Exhibit of Other Liabilities by Lines of Business As Reported on Line 17 of The Exhibit of Premiums and Losses

All reporting entities reporting “Other Liability” on Line 17 of the Exhibit of Premiums and Losses must prepare this exhibit. The exhibit is to be prepared and filed by all reporting entities no later than March 1 of each year. The purpose of the Exhibit of Other Liabilities by Lines of Business is to provide more information on the diverse lines of business filed on Annual Statement Line 17. The exhibit should be reported on a direct basis (before assumed and ceded reinsurance). For definitions of the products reported on Lines 1 through 28, see the appendix of these instructions. Line 29 – All Other will include all products not reported on Lines 1 through 28. Column 1 – Written Premium

Line 30 should equal Exhibit of Premiums and Losses Grand Total Page Column 1, Line 17.1 + Line 17.2 + Line 17.3.

Column 2 – Earned Premium


Column 3 – Unearned Premium Reserve


Column 4 – Losses Paid (Deducting Salvage)


Column 5 – Losses Incurred


Column 6 – Losses Unpaid (Case Base)

Line 30 should equal Underwriting and Investment Exhibit, Part 2A Column 1, Line 17.1 + Line 17.2 + Line 17.3.

Column 7 – Defense and Cost Containment Paid


Column 8 – Defense and Cost Containment Incurred


Attachment D


ANNUAL STATEMENT BLANK – PROPERTY SUPPLEMENT FOR THE YEAR OF THE .................................................. Affix Bar Code Above

EXHIBIT OF OTHER LIABILITIES BY LINES OF BUSINESS AS REPORTED ON LINE 17 OF THE EXHIBIT OF PREMIUMS AND LOSSES

(To Be Filed by March 1) NAIC Group Code ......................................... NAIC Company Code ...................................................... Company Name .............................................................................................................................................................................................................................................................................................................................

Direct Business Only 1 2 3 4 5 6 7 8 9

Written Premium Earned

Premium Unearned

Premium Reserve

Losses Paid (deducting salvage)

Losses Incurred

Losses Unpaid

(Case Base)

Defense and Cost

Containment Paid

Defense and Cost Containment

Incurred

Defense and Cost Containment

Unpaid (Case Base)

1. Completed Operations Liability .............................................................. ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 2. Construction and Alteration Liability ..................................................... ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 3. Contingent Liability ................................................................................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 4. Contractual Liability ............................................................................... ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 5. Elevators and Escalators Liability ........................................................... ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 6. Errors and Omissions Liability Professional Liability Other

Than Medical ........................................................................................... ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 7. Environmental Pollution Liability ........................................................... ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 8. Excess and Umbrella Liability ................................................................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 9. Liquor Liability ....................................................................................... ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 10. Personal Injury Liability .......................................................................... ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 11. Premises and Operations Liability .......................................................... ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 12. Excess Workers’ Compensation .............................................................. ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 13. Commercial General Liability ................................................................. ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 14. Comprehensive Personal Liability .......................................................... ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 15. Day Care Centers .................................................................................... ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 16. Directors and Officers Liability .............................................................. ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 17. Employee Benefit Liability ..................................................................... ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 18. Employers’ Liability ............................................................................... ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 19. Employment Practices Liability .............................................................. ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 20. Fire Legal Liability .................................................................................. ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 21. Municipal Liability .................................................................................. ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 22. Nuclear Energy Liability ......................................................................... ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 23. Veterinarian ............................................................................................. ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 24. Internet Liability ...................................................................................... ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 25. Cyber Liability ........................................................................................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 26. Fiduciary Liability ................................................................................. ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 27. Premises and Operations (OL&T and M&C) ...................................... ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 28. Professional Errors and Omissions Liability ....................................... ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ ............................ 29. All Other

30. Total ASL 17 – Other Liability (Sum of Lines 1 through 29)

Attachment D


SUPPLEMENTAL EXHIBITS AND SCHEDULES INTERROGATORIES

REQUIRED FILINGS

The following supplemental reports are required to be filed as part of your statement filing unless specifically waived by the domiciliary state. However, in the event that your domiciliary state waives the filing requirement, your response of WAIVED to the specific interrogatory will be accepted in lieu of filing a “NONE” report and a bar code will be printed below. If the supplement is required of your company but is not being filed for whatever reason, enter SEE EXPLANATION and provide an explanation following the interrogatory questions.

MARCH FILING RESPONSES

1. Will an actuarial opinion be filed by March 1? ....................................................


SUPPLEMENTAL FILINGS

The following supplemental reports are required to be filed as part of your statement filing if your company is engaged in the type of business covered by the supplement. However, in the event that your company does not transact the type of business for which the special report must be filed, your response of NO to the specific interrogatory will be accepted in lieu of filing a “NONE” report and a bar code will be printed below. If the supplement is required of your company but is not being filed for whatever reason, enter SEE EXPLANATION and provide an explanation following the interrogatory questions.

MARCH FILING

11. Will Schedule SIS (Stockholder Information Supplement) be filed with the state of domicile by March 1? ....................................................

12. Will the Financial Guaranty Insurance Exhibit be filed by March 1? ....................................................

13. Will the Medicare Supplement Insurance Experience Exhibit be filed with the state of domicile and the NAIC by March 1? ....................................................

14. Will Supplement A to Schedule T (Medical Professional Liability Supplement) be filed by March 1? ....................................................

15. Will the Trusteed Surplus Statement be filed with the state of domicile and the NAIC by March 1? ....................................................

16. Will the Premiums Attributed to Protected Cells Exhibit be filed by March 1? ....................................................

17. Will the Reinsurance Summary Supplemental Filing for General Interrogatory 9 be filed with the state of domicile and the NAIC by March 1? ....................................................

18. Will the Medicare Part D Coverage Supplement be filed with the state of domicile and the NAIC by March 1? ....................................................

19. Will the confidential Actuarial Opinion Summary be filed with the state of domicile, if required, by March 15 (or the date otherwise specified)?

20. Will the Reinsurance Attestation Supplement be filed with the state of domicile and the NAIC by March 1?

21. Will the Exceptions to the Reinsurance Attestation Supplement be filed with the state of domicile by March 1?

....................................................

....................................................

....................................................

22. Will the Bail Bond Supplement be filed with the state of domicile and the NAIC by March 1? ....................................................

23. Will the Director and Officer Insurance Coverage Supplement be filed with the state of domicile and the NAIC by March 1? ....................................................

24. Will an approval from the reporting entity’s state of domicile for relief related to the five-year rotation requirement for lead audit partner be filed


....................................................

25. Will an approval from the reporting entity’s state of domicile for relief related to the one-year cooling off period for independent CPA be filed


....................................................

26. Will an approval from the reporting entity’s state of domicile for relief related to the Requirements for Audit Committees be filed electronically

with the NAIC by March 1?

....................................................

27. Will the Supplemental Schedule for Reinsurance Counterparty Reporting Exception – Asbestos and Pollution contracts be filed with the state of domicile and the NAIC by March 1?

....................................................

28. Will the Exhibit of Other Liabilities by Lines of Business be filed with the state of domicile and the NAIC by March 1?

....................................................

APRIL FILING

2829. Will the Credit Insurance Experience Exhibit be filed with the state of domicile and the NAIC by April 1? ....................................................

2930. Will the Long-term Care Experience Reporting Forms be filed with the state of domicile and the NAIC by April 1? ....................................................

3031. Will the Accident and Health Policy Experience Exhibit be filed by April 1? ....................................................

3132. Will the Supplemental Health Care Exhibit (Parts 1, 2 and 3) be filed with the state of domicile and the NAIC by April 1? ....................................................

3233. Will the regulator-only (non-public) Supplemental Health Care Exhibit’s Allocation Report be filed with the state of domicile and the NAIC by April 1? ....................................................

3334. Will the Cybersecurity and Identity Theft Insurance Coverage Supplement be filed with the state of domicile and the NAIC by April 1? ....................................................

3435. Will the Life, Health & Annuity Guaranty Association Assessable Premium Exhibit – Parts 1 and 2 be filed with the state of domicile and the NAIC by April 1? ....................................................

3536. Will the Private Flood Insurance Supplement be filed with the state of domicile and the NAIC by April 1? ....................................................

3637. Will the Mortgage Guaranty Insurance Exhibit be filed with the state of domicile and the NAIC by April 1?

AUGUST FILING

3738. Will Management’s Report of Internal Control Over Financial Reporting be filed with the state of domicile by August 1? ....................................................


Attachment E

© 2021 National Association of Insurance Commissioners 2021-14BWG_Modified.doc 1



DATE: 04/19/2021

CONTACT PERSON:

TELEPHONE:


NAME: Shawn Frederick

TITLE: Assistant Chief Examiner

AFFILIATION: Texas Department of Insurance

ADDRESS:

FOR NAIC USE ONLY Agenda Item # 2021-14BWG MOD Year 2022 Changes to Existing Reporting [ X ] New Reporting Requirement [ ]






[ X ] Life, Accident & Health/Fraternal [ ] Separate Accounts [ ] Title [ X ] Property/Casualty [ ] Protected Cell [ ] Other _______________________ [ ] Health [ ] Health (Life Supplement)


IDENTIFICATION OF ITEM(S) TO CHANGE Expanded the number of lines of business reported on Schedule H to match the lines of business reported on the Health Statement. Modified the instructions so they will be uniform between life/fraternal and property.

REASON, JUSTIFICATION FOR AND/OR BENEFIT OF CHANGE** The purpose of the proposal is to bring uniformity in the accident and health lines of business used on Schedule H with other schedules and exhibits in the annual statement.


Attachment E



SCHEDULE H

ACCIDENT AND HEALTH EXHIBIT Life/Fraternal: “Appropriately” where used in the Instructions for Schedule H, means the appropriate accident and health

portions of referenced data. Reconciliation with figures drawn from other parts of the statement may only be possible with respect to Group Accident and Health (Column 3), Credit (Group and Individual) Accident and Health (Column 5) and Other Accident and Health (the combination of Columns 7 through 17), and, in some cases, may only be possible with respect to Total Accident and Health (Column 1) of Schedule H – Accident and Health Exhibit.

For definitions of lines of business, see the appendix of these instructions. All amounts reportable in Parts 1 through 3 are net of reinsurance ceded, i.e., reinsurance assumed should be included, reinsurance ceded should be deducted, and net figures entered in the statement. Part 4, “Reinsurance,” displays the reinsurance assumed and ceded components. Column 5 – Credit Accident and Health (Group and Individual)

Include: Business not exceeding 120 months duration.

This column is not applicable to Fraternal Benefit Societies. Column 7 – Collectively Renewable

Include: Amounts pertaining to policies/certificates that are made available to groups of persons under a plan sponsored by an employer, or an association or a union of affiliated associations or unions, or a group of individuals supplying materials to a central point of collection or handling a common product or commodity, under which the reporting entity has agreed with respect to such policies/certificates that renewal will not be refused, subject to any specified age limit, while the reporting entity remains a member of the group specified in the agreement unless the reporting entity simultaneously refuses renewal to all other policies/certificates in the same group. A sponsored plan shall not include any arrangement where a reporting entity’s customary individual policies/certificates are made available without special underwriting considerations, and where the employer’s participation is limited to arranging for salary allotment premium payments with or without contribution by the employer. Such plans are sometimes referred to as payroll budget or salary allotment plans. A sponsored plan may be administered by an agent or trustee.

Amounts pertaining to policies/certificates issued by a company or group of companies under a plan, other than a group insurance plan, authorized by special legislation for the exclusive benefit of the aged through mass enrollment.

Amounts pertaining to policies/certificates issued under mass enrollment procedures to older people, such as those age 65 and over, in some geographic region or regions under which the reporting entity has agreed with respect to such policies/certificates that renewal will not be refused unless the reporting entity simultaneously refuses renewal to all other policies/certificates specified in the agreement.

Attachment E


Column 9 – Non-cancelable

Include: Amounts pertaining to policies/certificates that are guaranteed renewable for life or to a specified age, such as 60 or 65, at guaranteed premium rates.

Column 11 – Guaranteed Renewable

Include: Amounts pertaining to policies/certificates that are guaranteed renewable for life or to a specified age, such as 60 or 65, but under which the reporting entity reserves the right to change the scale of premium rates.

Column 13 – Non-renewable for Stated Reasons Only

Include: Amounts pertaining to policies/certificates in which the reporting entity has reserved the right to cancel or refuse renewal for one or more stated reasons, but has agreed implicitly or explicitly that, prior to a specified time or age, it will not cancel or decline renewal solely because of deterioration of health after issue.

Column 17 – All Other

Include: Any other accident and health coverages not specifically required in other columns. All Medicare Part D Prescription Drug Coverage, whether sold on a stand-alone basis or through a Medicare Advantage product and whether sold directly to an individual or through a group.

PART 1 – ANALYSIS OF UNDERWRITING OPERATIONS In each % column of Part 1, show the percentage of Line 2 for Lines 3 through 14 inclusive. Line 1 – Premiums Written

Life/Fraternal: Column 1 should agree with Schedule T, Column 4 Line 97 minus Line 98 if prepared on a written basis.

Property: Column 1 should agree with Underwriting and Investment Exhibit, Part 1B sum of

Lines 13 through 15 (Column 1 + 2 + 3).

Columns 3, 5, 7, 9, 11, 13, 15, 17, 19, 21, 23 and 25 should agree with Underwriting and Investment Exhibit, Part 1B Column 1 + 2 + 3 Lines 13.1, 13.2, 14, 15.1, 15.2, 15.3, 15.4, 15.5, 15.6, 15.7, 15.8 and 15.9 respectively.

Should agree with “Total (All Business) minus Reinsurance Ceded” Line of Column 4, Schedule T, if prepared on a written basis.

Line 2 – Premiums Earned

Refer to SSAP No. 54R—Individual and Group Accident and Health Contracts for accounting guidance.

Should agree with Line 1 plus the change in unearned premiums and reserve for rate credits included in Part 2, Section A.

Attachment E


Line 3 – Incurred Claims

Report cash settlements during the year plus the change in claim liabilities, reserves and amounts recoverable from reinsurers.

Life/Fraternal: Should agree appropriately with both Exhibit 8, Part 2, Line 6.4 and also with

Analysis of Operations by Lines of Business – Summary, Column 6, Line 13, in each case adjusted for the change in Exhibit 6 of Aggregate Accident and Health Reserves, Line 16 reserves.

Property: Column 1 should agree with Underwriting and Investment Exhibit, Part 2 sum of

Lines 13 through 15 (Column 7).

Should agree with Schedule H, Part 2, Section C, Line 3; plus Schedule H, Part 3, Line 1.1; plus Schedule H, Part 3, Line 1.2.

Line 4 – Cost Containment Expenses

Report cost containment expenses in accordance with SSAP No. 55—Unpaid Claims, Losses and Loss Adjustment Expenses.

Life/Fraternal: Should agree with Exhibit 2, Column 2, Line 10.

Property: Column 1 (Line 4 plus Line 8) should agree with the Insurance Expense Exhibit,

Part II (Columns 9 + Column 11 + Column 27 and+ 29) sum of Lines 13 through 15.

Column 3 – Line 4 plus Line 8 should agree with the Insurance Expense Exhibit, Part II (Columns 9 + Column 11 + Column 27 and+ 29), Lines 13.1.

Column 5 – Line 4 plus Line 8 should agree with the Insurance Expense

Exhibit, Part II (Columns 9 + Column 11 + Column 27 and+ 29), Lines 13.2.




Exhibit, Part II (Columns 9 + Column 11 + Column 27 and+ 29), Lines 15.15





Attachment E






Exhibit, Part II (Columns 9 + Column 11 + Column 27 and+ 29), Lines 14.







Line 5 – Incurred Claims and Cost Containment Expenses

Should agree with the sum of Lines 3 and 4. Line 6 – Increase in Contract Reserves

Should agree with Part 2, Section B, Line 5. Line 7 – Commissions

Report incurred commissions and expense allowances on reinsurance.

Life/Fraternal: Should agree appropriately with the net of Exhibit 1, Part 2, Line 31 minus Line 26.3 and also with the net of Analysis of Operations by Lines of Business – Summary, Column 6, Line 21 plus Line 22, minus Line 6, Accident and Health columns.

Property: Column 1 should agree with Insurance Expense Exhibit, Part II sum of Lines 13

through 15 (Column 23).

Column 3 – Should agree with the Insurance Expense Exhibit, Part II, Column 23, Lines 13.1.

Column 5 – Should agree with the Insurance Expense Exhibit, Part II,

Column 23, Lines 13.2.


Attachment E


Column 9 – Should agree with the Insurance Expense Exhibit, Part II, Column 23, Lines 15.15








Column 23, Lines 14.





Line 8 – Other General Insurance Expenses

Report general insurance expenses incurred and provision for claim expenses incurred in connection with pending and incurred but unreported claims not included in Cost Containment Expenses on Line 4 above.

Life/Fraternal: Should agree appropriately with Exhibit 2, Column 3, Line 10.

Line 9 – Taxes, Licenses and Fees

Report total taxes (excluding federal income taxes) plus state insurance department licenses and fees.

Life/Fraternal: Should agree appropriately with Exhibit 3, Column 2, Line 7 and also with Analysis of Operations by Lines of Business – Summary, Column 6, Line 24, Accident and Health columns.







Attachment E















Line 10 – Total Other Expenses Incurred

Sum of Lines 7, 8 and 9. Line 11 – Aggregate Write-ins for Deductions

Enter the total of the write-ins listed in schedule “Details of Write-ins Aggregated at Line 11 for Deductions.”

Line 12 – Gain from Underwriting Before Dividends or Refunds

Report premiums earned less incurred claims, less increase in policy reserves and less total expenses incurred. Line 2 less the sum of Lines 5, 6, 10 and 11.

Line 13 – Dividends or Refunds

Life/Fraternal: Should agree appropriately with Analysis of Operations by Lines of Business – Summary, Column 6, Line 30, Accident and Health columns, and also with Exhibit 4, Dividends or Refunds, Column 2, Line 17.






Attachment E




Column 5, Lines 15.15







Column 19 – Should agree with the Insurance Expense Exhibit, Part II, Column 5, Lines 14.





Column 5, Lines 15.9. Line 14 – Gain From Underwriting After Dividends or Refunds

Line 12 minus Line 13. Details of Write-ins Aggregated on Line 11 for Deductions

List separately all deductions for which there is no pre-printed line on Schedule H – Part 1.

Include: Group conversions, transfers on account of group package policies and contracts, etc.

Attachment E


PART 2 – RESERVES AND LIABILITIES

SECTION A – PREMIUM RESERVES Line 1 – Unearned Premiums

Life/Fraternal: Should agree appropriately with Exhibit 6, Line 1, net of applicable reinsurance ceded.

Line 2 – Advance Premiums

Life/Fraternal: Should agree appropriately with the sum of Exhibit 1, Part 1, Lines 4 and 14.

Property: Column 1 should agree with Underwriting and Investment Exhibit, Part 1A, Column 1 plus Column 2, sum of Lines 13, 14 and 15.

Line 3 – Reserve for Rate Credits

Life/Fraternal: Should agree appropriately with the net of Exhibit 6, Line 5, net of applicable reinsurance ceded, plus Page 3, Line 9.2 parenthetical amount #1 minus Page 2, Line 15.3, Column 3, accident and health portion.

Not applicable to Fraternal Benefit Societies.

Property: Column 1 should agree with Underwriting and Investment Exhibit, Part 1A,

Column 4, sum of Lines 13, 14 and 15.

Column 2 – Should agree with the Underwriting and Investment Exhibit, Part 1A, Column 4, Lines 13.1.

Column 3 – Should agree with the Underwriting and Investment Exhibit,

Part 1A, Column 4, Lines 13.2.



Part 1A, Column 4, Lines 15.15







Column 10 – Should agree with the Underwriting and Investment Exhibit, Part 1A, Column 4, Lines 14.

Attachment E






Line 4 – Total Premium Reserves, Current Year

Sum of Lines 1, 2 and 3. Line 5 – Total Premium Reserves, Prior Year

Line 4 from prior year. (For 2022 this only applies to Column 1. For 2023 it applies to all columns.) Line 6 – Increase in Total Premium Reserves

Line 4 minus Line 5.

SECTION B – CONTRACT RESERVES Line 1 – Additional Reserves


Include: Premium deficiency reserve.

Companies must carry a reserve in this line for any policy or block of policies:

(i) With which level premiums are used, or (ii) With respect to which, due to the gross premium structure at issue, the value of future benefits

exceeds the value of appropriate future valuation net premiums.

Companies must carry a reserve for any block of contracts for which future gross premiums when reduced by expenses for administration, commissions, and taxes will be insufficient to cover future claims or services.

Line 2 – Reserve for Future Contingent Benefits

Companies must carry a reserve on this line that provides for the extension of benefits after termination of the policy or of any insurance thereunder. Such benefits, that actually accrue and are payable at some future date, are predicated on a condition or actual disability that exists at the termination of the insurance and that is usually not known to the insurance company. These benefits are normally provided by contract provision but may be payable because of court decisions or of departmental rulings.

An example of the type of benefit for which a reserve must be carried is the coverage for hospital confinement after the termination of an employee’s certificate but prior to the expiration of a stated period. This example is illustrative only and is not intended to limit the reserve to the benefits described. Some individual Accident and Health policies may also provide benefits similar to those under the “Extension of Benefits” section of a group policy.

Attachment E


Line 3 – Total Contract Reserves, Current Year

Sum of Lines 1 and 2. Line 4 – Total Contract Reserves, Prior Year

Line 3 from prior year. (For 2022 this only applies to Column 1. For 2023 it applies to all columns.) Line 5 – Increase in Contract Reserves


SECTION C – CLAIM RESERVES AND LIABILITIES Line 1 – Total Current Year

Life/Fraternal: Should agree appropriately with the sum of Exhibit 6, Line 16 and Exhibit 8, Part 1, Line 4.4.



Also should agree with Part 3, Line 2.1 plus Part 3, Line 2.2 below. Line 2 – Total Prior Year

Line 1 from prior year. (For 2022 this only applies to Column 1. For 2023 it applies to all columns.)

Should agree with Part 3, Line 3.2 below.

Property: Column 13 should agree with Underwriting and Investment Exhibit, Part 2, Column 6, sum of Lines 13, 14 and 15.

Line 3 – Increase


Attachment E


PART 3 – TEST OF PRIOR YEAR’S CLAIM RESERVES AND LIABILITIES Lines 1.1 and 1.2 – Claims Paid During the Year on Claims Incurred Prior to and During Current Year

Represents net payments made during the year less the change in amounts still recoverable from reinsurance.

Life/Fraternal: The sum of Lines 1.1 and 1.2 should agree appropriately with Exhibit 8, Part 2,

Lines 1.4 minus Line 3 plus Line 5. Lines 2.1, 2.2 and 3.2 – Claim Reserves and Liabilities, December 31 on Claims Incurred Prior to and During Current Year.

The sum of Lines 2.1 and 2.2 should equal Line C1 of Part 2 of this schedule and Line 3.2 should equal Line C2 of Part 2 of this Schedule. Line 3.3 represents the result of the test for adequacy of claim provisions. A negative figure will normally indicate a favorable reserve development.

PART 4 – REINSURANCE Represents the reinsurance assumed and ceded components of Part 1, Lines 1, 2, 3 and 7 of this schedule.

SECTIONS A AND B Line 2 – Premiums Earned

Premiums earned are before adjustment for the increase in policy reserves that has been treated as a separate deduction.

SECTION A – REINSURANCE ASSUMED



SECTION B – REINSURANCE CEDED



Attachment E


PART 5 – HEALTH CLAIMS Companies with less than 5% of premiums in Accident and Health business should not complete this schedule. Column 3 – Other

Include: All Medicare Part D Prescription Drug Coverage, whether sold on a stand-alone basis or through a Medicare Advantage product and whether sold directly to an individual or through a group.

A. DIRECT


Should agree with Line 3 plus Line 4 minus Line 2.

Line 2 – Beginning Claim Reserves and Liabilities

Life/Fraternal: Column 13 Sshould agree with Exhibit 8, Part 2, Line 4.1, sum of Columns 9, 10 and 11, plus direct portion of Exhibit 6, Line 14, Column 1, Prior Year.

Line 3 – Ending Claim Reserves and Liabilities

Life/Fraternal: Column 13 Sshould agree with Exhibit 8, Part 2, Line 2.1, sum of Columns 9, 10 and

11, plus direct portion of Exhibit 6, Line 14, Column 1.

Line 4 – Claims Paid

Life/Fraternal: Column 13 Sshould agree with Exhibit 8, Part 2, Line 1.1, sum of Columns 9, 10 and 11.

Property: Column 13 should agree with Underwriting and Investment Exhibit, Part 2,


Column 1 – Should agree with the Underwriting and Investment Exhibit, Part 2, Column 1, Lines 13.1.


Part 2, Column 1, Lines 13.2.



Part 2, Column 1, Lines 15.15







Attachment E


Column 9 – Should agree with the Underwriting and Investment Exhibit, Part 2, Column 1, Lines 14.





Part 2, Column 1, Lines 15.9. B. ASSUMED REINSURANCE


Columns 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13 should Should agree with Schedule H, Part 4, Line A3, Columns 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 1, respectively.

Should also agree with Line 37 plus Line 48, minus Line 26.



11 plus assumed portion of Exhibit 6, Line 14, Column 1, Prior Year.


Life/Fraternal: Column 13 Sshould agree with Exhibit 8, Part 2, Line 2.2, sum of Columns 9, 10 and 11, plus assumed portion of Exhibit 6, Line 14, Column 1.



11.







Column 4 – Should agree with the Underwriting and Investment Exhibit, Part 2, Column 2, Lines 15.15






Attachment E




Part 2, Column 2, Lines 14.





C. CEDED REINSURANCE


Columns 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13 should Should agree with Schedule H, Part 4, Line B3, Columns 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 1, respectively.

Should also agree with Line 113, plus Line 124, minus Line 102.


Include: Amounts recoverable from reinsurers.

Life/Fraternal: Column 13 Sshould agree with Exhibit 8, Part 2, Line 4.3, plus Line 5, sum of

Columns 9, 10 and 11, plus Exhibit 6, Line 15, Column 1, Prior Year.



Life/Fraternal: Column 13 Sshould agree with Exhibit 8, Part 2, Line 2.3, plus Line 3, sum of Columns 9, 10 and 11, plus Exhibit 6, Line 15, Column 1.



11.








Attachment E













Part 2, Column 3, Lines 15.9. D. NET


Columns 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13 should Should agree with Schedule H, Part 1, Line 3, Columns 3, 5, 7, 9, 11, 13, 15, 17,19, 21, 23, 25 and 1.



Life/Fraternal: Column 13 Sshould agree with Schedule H, Part 2, Line C2, Column 1, minus

Exhibit 8, Part 2, Line 5, sum of Columns 9, 10 and 11.

Property: Columns 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13 should agree with Schedule H, Part 2, Line C2, Columns 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 1, respectively.


Exclude: Amounts recoverable from reinsurers.

Life/Fraternal: Column 13 Sshould agree with Schedule H, Part 2, Line C1, Column 1, minus



Attachment E



Life/Fraternal: Column 13 Sshould agree with Exhibit 8, Part 2, Line 1.4, sum of Columns 9, 10 and 11.

Property: Column 13 should agree with Underwriting and Investment Exhibit, Part 2,




















Attachment E


E. NET INCURRED CLAIMS AND COST CONTAINMENT EXPENSES


Should agree with Schedule H, Part 1, Line 5, Column 1.

Line 218 – Beginning Reserves and Liabilities

Life/Fraternal: Column 13 Sshould agree with Exhibit 2, Column 2, Line 11 plus Line 214 above.

Property: Should agree with Underwriting and Investment Exhibit, Part 3, Column 1 (in part), plus Line 214 above.

Line 319 – Ending Reserves and Liabilities

Life/Fraternal: Column 13 Sshould agree with Exhibit 2, Column 2, Line 12 plus Line 315 above.

Property: Should agree with Underwriting and Investment Exhibit, Part 3, Column 1 (in part),

plus Line 315 above.

Line 420 – Paid Claims and Cost Containment Expenses

Line 17 1 plus Line 18 2 minus Line 193.

Attachment E


ANNUAL STATEMENT INSTRUCTIONS –PROPERTY

SCHEDULE H

ACCIDENT AND HEALTH EXHIBIT Life/Fraternal: “Appropriately” where used in the Instructions for Schedule H, means the appropriate accident and health

portions of referenced data. Reconciliation with figures drawn from other parts of the statement may only be possible with respect to Group Accident and Health (Column 3), Credit (Group and Individual) Accident and Health (Column 5) and Other Accident and Health (the combination of Columns 7 through 17), and, in some cases, may only be possible with respect to Total Accident and Health (Column 1) of Schedule H – Accident and Health Exhibit.

For definitions of lines of business, see the appendix of these instructions. All amounts reportable in Parts 1 through 3 are net of reinsurance; (i.e., reinsurance assumed should be included, reinsurance ceded should be deducted, and net figures entered in the statement.) Part 4, Reinsurance displays the reinsurance assumed and ceded components. Column 5 – Credit A & H (Group and Individual)

Include: Business not exceeding 120 months duration. Column 7 – Collectively Renewable

Include: Amounts pertaining to policies that are made available to groups of persons under a plan sponsored by an employer, or an association or a union or affiliated associations or unions or a group of individuals supplying materials to a central point of collection or handling a common product or commodity, under which the reporting entity has agreed with respect to such policies that renewal will not be refused, subject to any specified age limit, while the insured remains a member of the group specified in the agreement unless the reporting entity simultaneously refuses renewal to all other policies in the same group. A sponsored plan shall not include any arrangement where a reporting entity’s customary individual policies are made available without special underwriting considerations and where the employer’s participation is limited to arranging for salary allotment premium payments with or without contribution by the employer. Such plans are sometimes referred to as payroll budget or salary allotment plans. A sponsored plan may be administered by an agent or trustee.

Amounts pertaining to policies issued by a company or group of companies under a plan, other than a group insurance plan, authorized by special legislation for the exclusive benefit of the aged through mass enrollment.

Amounts pertaining to policies issued under mass enrollment procedures to older people, such as those age 65 and over, in some geographic region or regions under which the reporting entity has agreed with respect to such policies that renewal will not be refused unless the reporting entity simultaneously refuses renewal to all other policies specified in the agreement.

Column 9 – Non-Cancelable

Include: Amounts pertaining to policies, which are guaranteed renewable for life or to a specified age, such as 60 or 65, at guaranteed premium rates.

Attachment E


Column 11 – Guaranteed Renewable

Include: Amounts pertaining to policies that are guaranteed renewable for life or to a specified age, such as 60 or 65, but under which the reporting entity reserves the right to change the scale of premium rates.

Column 13 – Non-Renewable for Stated Reasons Only

Include: Amounts pertaining to policies in which the reporting entity has reserved the right to cancel or refuse renewal for one or more stated reasons, but has agreed implicitly or explicitly that, prior to a specified time or age, it will not cancel or decline renewal solely because of deterioration of health after issue.

Column 17 – All Other

Include: Any other accident and health coverages not specifically required in other columns. All Medicare Part D Prescription Drug Coverage, whether sold on a stand-alone basis or through a Medicare Advantage product and whether sold directly to an individual or through a group.

PART 1 – ANALYSIS OF UNDERWRITING OPERATIONS In each “%” column of Part 1, show the percentages of Line 2 for Lines 3 through 14 inclusive. Line 1 – Premiums Written

Life/Fraternal: Column 1 should agree with Schedule T, Column 4 Line 97 minus Line 98 if prepared on a written basis.

Property: Column 1 should agree with Underwriting and Investment Exhibit, Part 1B sum of


Should agree appropriately with those shown in the Underwriting and Investment Exhibit, Part 1B. Line 2 – Premiums Earned


Should agree with Line 1 plus the change in unearned premiums and reserve for rate credits included in Part 2, Section A.

Should agree appropriately with those shown in the Underwriting and Investment Exhibit, Part 1.


Report cash settlements during the year plus the change in claim liabilities, reserves and amounts recoverable from reinsurers.

Life/Fraternal: Should agree appropriately with both Exhibit 8, Part 2, Line 6.4 and also with

Analysis of Operations by Lines of Business – Summary, Column 6, Line 13, in each case adjusted for the change in Exhibit 6 of Aggregate Accident and Health Reserves, Line 16 reserves.

Attachment E


Should agree appropriately with losses incurred as shown in the Underwriting and Investment Exhibit, Part 2.



Should agree with Schedule H, Part 2, Section C, Line 3; plus Schedule H, Part 3, Line 1.1; plus Schedule H, Part 3, Line 1.2.

Line 4 – Cost Containment Expenses

Report cost containment expenses in accordance with SSAP No. 55—Unpaid Claims, Losses and Loss Adjustment Expenses.

Life/Fraternal: Should agree with Exhibit 2, Column 2, Line 10.

Line 4 plus Line 8 should agree appropriately with the sum of Columns 9, 11, 27 and 29 of the Insurance Expense Exhibit, Part II.

Property: Column 1 (Line 4 plus Line 8) should agree with the Insurance Expense Exhibit,

Part II (Columns 9 + Column 11 + Column 27 and+ 29) sum of Lines 13 through 15.







Exhibit, Part II (Columns 9 + Column 11 + Column 27 and+ 29), Lines 15.5









Attachment E


Column 19 – Line 4 plus Line 8 should agree with the Insurance Expense Exhibit, Part II (Columns 9 + Column 11 + Column 27 and+ 29), Lines 14.








Sum of Lines 3 and 4. Line 6 – Increase in Contract Reserves

Should agree with Schedule H, Part 2, Section B, Line 5. Line 7 – Commissions

Report incurred commissions and expense allowances on reinsurance.

Life/Fraternal: Should agree appropriately with the net of Exhibit 1, Part 2, Line 31 minus Line 26.3 and also with the net of Analysis of Operations by Lines of Business – Summary, Column 6, Line 21 plus Line 22, minus Line 6, Accident and Health columns.

Should agree appropriately with Column 23 of Insurance Expense Exhibit, Part II.








Column 23, Lines 15.5


Attachment E












Line 8 – Other General Insurance Expenses

Report general insurance expenses incurred and provision for claim expenses incurred in connection with pending and incurred but unreported claims not included in Cost Containment Expenses on Line 4 above.

Life/Fraternal: Should agree appropriately with Exhibit 2, Column 3, Line 10.

Line 4 plus Line 8 should agree appropriately with the sum of Columns 9, 11, 27 and 29 of the Insurance Expense Exhibit, Part II.

Line 9 – Taxes, Licenses and Fees

Report total taxes (excluding federal income taxes) plus state insurance department licenses and fees.

Life/Fraternal: Should agree appropriately with Exhibit 3, Column 2, Line 7 and also with Analysis of Operations by Lines of Business – Summary, Column 6, Line 24, Accident and Health columns.

Should agree appropriately with Column 25 of the Insurance Expense Exhibit, Part II.







Attachment E















Line 10 – Total Other Expenses Incurred

Sum of Lines 7, 8 and 9. Line 11 – Aggregate Write-ins for Deductions

Enter the total of the write-ins listed in Schedule Detail of Write-ins Aggregated at Line 11 for Deductions.

Line 12 – Gain From Underwriting Before Dividends or Refunds

Report premiums earned less incurred claims, less increase in policy reserves and less total expenses incurred. Line 2 minus the sum of Lines 5, 6, 10 and 11.

Line 13 – Dividends or Refunds

Life/Fraternal: Should agree appropriately with Analysis of Operations by Lines of Business – Summary, Column 6, Line 30, Accident and Health columns, and also with Exhibit 4, Dividends or Refunds, Column 2, Line 17.

Should agree appropriately with Column 5 of the Insurance Expense Exhibit, Part II.

Attachment E


Property: Column 1 should agree with Insurance Expense Exhibit, Part II sum of Lines 13 through 15 (Column 5).














Column 5, Lines 14.





Line 14 – Gain From Underwriting After Dividends or Refunds

Line 12 minus Line 13. Details of Write-ins Aggregated at Line 11 for Deductions

List separately each category of deductions for which there is no pre-printed line on Schedule H, Part 1.

Include: Group conversions, transfers on account of group package policies and contracts, etc.

Attachment E



SECTION A – PREMIUM RESERVES Should agree appropriately with those in the Underwriting and Investment Exhibit, Part 1A minus amounts reported as contract reserves in Schedule H, Part 2, Section B, below. Line 1 – Unearned Premiums

Life/Fraternal: Should agree appropriately with Exhibit 6, Line 1, net of applicable reinsurance ceded.


Column 1 plus Column 2, sum of Lines 13, 14 and 15. Line 2 – Advance Premiums

Life/Fraternal: Should agree appropriately with the sum of Exhibit 1, Part 1, Lines 4 and 14. Line 3 – Reserve for Rate Credits

Life/Fraternal: Should agree appropriately with the net of Exhibit 6, Line 5, net of applicable reinsurance ceded, plus Page 3, Line 9.2 parenthetical amount #1 minus Page 2, Line 15.3, Column 3, accident and health portion.

Not applicable to Fraternal Benefit Societies.








Part 1A, Column 4, Lines 15.5







Column 10 – Should agree with the Underwriting and Investment Exhibit, Part 1A, Column 4, Lines 14.

Attachment E






Line 4 – Total Premium Reserves, Current Year

Sum of Lines 1, 2 and 3. Line 5 – Total Premium Reserves, Prior Year

Line 4 from prior year. (For 2022 this only applies to Column 1. For 2023 it applies to all columns.) Line 6 – Increase in Total Premium Reserves


SECTION B – CONTRACT RESERVES Line 1 – Additional Reserves


Include: Premium deficiency reserve.

Companies must carry a reserve in this line for any policy or block of policies:

(i) With which level premiums are used, or

(ii) With respect to which, due to the gross premium structure at issue, the value of future benefits exceeds the value of appropriate future valuation net premiums.

Companies must carry a reserve for any block of contracts for which future gross premiums when reduced by expenses for administration, commissions, and taxes will be insufficient to cover future claims or services.

Line 2 – Reserve for Future Contingent Benefits

Companies must carry a reserve on this line that provides for the extension of benefits after termination of the policy or of any insurance thereunder. Such benefits, that actually accrue and are payable at some future date, are predicated on a condition or actual disability that exists at the termination of the insurance and that is usually not known to the insurance company. These benefits are normally provided by contract provision but may be payable because of court decisions or of departmental rulings.

An example of the type of benefit for which a reserve must be carried is the coverage for hospital confinement after the termination of an employee’s certificate but prior to the expiration of a stated period. This example is illustrative only and is not intended to limit the reserve to the benefits described. Some individual Accident and Health policies may also provide benefits similar to those under the “Extension of Benefits” section of a group policy.

Attachment E


Line 3 – Total Contract Reserves, Current Year

Sum of Lines 1 and 2. Line 4 – Total Contract Reserves, Prior Year

Line 3 from prior year. (For 2022 this only applies to Column 1. For 2023 it applies to all columns.) Line 5 – Increase in Contract Reserves


SECTION C – CLAIM RESERVES AND LIABILITIES Line 1 – Total Current Year

Life/Fraternal: Should agree appropriately with the sum of Exhibit 6, Line 16 and Exhibit 8, Part 1, Line 4.4.



Should agree appropriately with Net Losses Unpaid shown in the Underwriting and Investment Exhibit, Part 2, Column 5.

Also should agree with Schedule H, Part 3, Line 2.1; plus Schedule H, Part 3, Line 2.2 below.

Line 2 – Total Prior Year

Line 1 from prior year. (For 2022 this only applies to Column 1. For 2023 it applies to all columns.)

Should agree with Schedule H, Part 3, Line 3.2 below.


Line 3 – Increase


Attachment E


PART 3 – TEST OF PRIOR YEAR’S CLAIM RESERVES AND LIABILITIES Lines 1.1 and 1.2 – Claims Paid During the Year on Claims Incurred Prior to and During Current Year

Represents net payments made during the year less the change in amounts still recoverable from reinsurance.

Life/Fraternal: The sum of Lines 1.1 and 1.2 should agree appropriately with Exhibit 8, Part 2,

Lines 1.4 minus Line 3 plus Line 5. Lines 2.1, 2.2 and 3.2 – Claim Reserves and Liabilities, December 31 on Claims Incurred Prior to and During Current Year

The sum of lines 2.1 and 2.2 should equal Line C1 of Part 2 of this schedule and Line 3.2 should equal Line C2 of Part 2 of this schedule. Line 3.3 represents the result of the test for adequacy of claim provisions. A negative figure will normally indicate a favorable reserve development.

PART 4 – REINSURANCE Represents the reinsurance assumed and ceded components of Part 1, Lines 1, 2, 3 and 7 of this schedule.

SECTIONS A AND B Line 2 – Premiums Earned


PART 5 – HEALTH CLAIMS Companies with less than 5% of premiums in Accident and Health business should not complete this schedule. Column 3 – Other

Include: All Medicare Part D Prescription Drug Coverage, whether sold on a stand-alone basis or through a Medicare Advantage product and whether sold directly to an individual or through a group.

A. DIRECT


Should agree with Line 3 plus Line 4 minus Line 2.

Attachment E



Life/Fraternal: Column 13Sshould agree with Exhibit 8, Part 2, Line 4.1, sum of Columns 9, 10 and 11, plus direct portion of Exhibit 6, Line 14, Column 1, Prior Year.


Life/Fraternal: Column 13Sshould agree with Exhibit 8, Part 2, Line 2.1, sum of Columns 9, 10 and

11, plus direct portion of Exhibit 6, Line 14, Column 1.


Life/Fraternal: Column 13Sshould agree with Exhibit 8, Part 2, Line 1.1, sum of Columns 9, 10 and 11.

Property: Column 13 Should should agree with Underwriting and Investment Exhibit, Part 2,




















Attachment E


B. ASSUMED REINSURANCE


Columns 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13 should Should agree with Schedule H, Part 4, Line A3, Columns 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 1, respectively.

Should also agree with Line 37 plus Line 48, minus Line 26.



11 plus assumed portion of Exhibit 6, Line 14, Column 1, Prior Year.


Life/Fraternal: Column 13Sshould agree with Exhibit 8, Part 2, Line 2.2, sum of Columns 9, 10 and 11, plus assumed portion of Exhibit 6, Line 14, Column 1.



11.

Property: Column 13 Should should agree with Underwriting and Investment Exhibit, Part 2, Column 2, sum of Lines 13, 14 and 15.


















Attachment E



Part 2, Column 2, Lines 15.9. C. CEDED REINSURANCE


Columns 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13 should Should agree with Schedule H, Part 4, Line B3, Columns 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 1, respectively.




Life/Fraternal: Column 13Sshould agree with Exhibit 8, Part 2, Line 4.3, plus Line 5, sum of

Columns 9, 10 and 11, plus Exhibit 6, Line 15, Column 1, Prior Year.



Life/Fraternal: Column 13Sshould agree with Exhibit 8, Part 2, Line 2.3, plus Line 3, sum of Columns 9, 10 and 11, plus Exhibit 6, Line 15, Column 1.



11.














Attachment E







Part 2, Column 3, Lines 15.9. D. NET


Columns 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13 should agree with Schedule H, Part 1, Line 3, Columns 3, 5, 7, 9, 11, 13, 15, 17,19, 21, 23, 25 and 1.


Should agree with Underwriting and Investment Exhibit, Part 2, Column 7, sum of Lines 13, 14 and 15 and Schedule H, Part 1, Line 3, Column 1.


Life/Fraternal: Column 13Sshould agree with Schedule H, Part 2, Line C2, Column 1, minus



Should agree with Underwriting and Investment Exhibit, Part 2, Column 6, sum of Lines 13, 14 and 15 and Schedule H, Part 2, Line C2, Column 1.


Exclude: Amounts recoverable from reinsurers.

Life/Fraternal: Column 13Sshould agree with Schedule H, Part 2, Line C1, Column 1, minus



Should agree with Underwriting and Investment Exhibit, Part 2, Column 5, sum of Lines 13, 14 and 15 and Schedule H, Part 2, Line C1, Column 1.



11.




Attachment E


















E. NET INCURRED CLAIMS AND COST CONTAINMENT EXPENSES


Should agree with Schedule H, Part 1, Line 5, Column 1.

Line 218 – Beginning Reserves and Liabilities

Life/Fraternal: Column 13Sshould agree with Exhibit 2, Column 2, Line 11 plus Line 14 above.

Property: Should agree with Underwriting and Investment Exhibit, Part 3, Column 1 (in part), plus Line 14 above.

Line 319 – Ending Reserves and Liabilities

Life/Fraternal: Column 13Sshould agree with Exhibit 2, Column 2, Line 12 plus Line 15 above.

Property: Should agree with Underwriting and Investment Exhibit, Part 3, Column 1 (in part),

plus Line 15 above.

Line 420 – Paid Claims and Cost Containment Expenses

Line 117 plus Line 218 minus Line 319.

Attachment E


UNDERWRITING AND INVESTMENT EXHIBIT

PART 1 – PREMIUMS EARNED Column 1 – Net Premiums Written

The amounts reported for the lines in this column should agree with the amounts reported for the identical line in Column 6 of the Underwriting and Investment Exhibit, Part 1B.

Column 2 – Unearned Premiums December 31 Prior Year

The amounts reported for the lines in this column should agree with the amounts reported for the identical line in Column 3 of the prior year Underwriting and Investment Exhibit, Part 1.

Column 3 – Unearned Premiums December 31 Current Year

The amounts reported for the lines in this column should agree with the amounts reported for the identical line in Column 5 of the Underwriting and Investment Exhibit, Part 1A.

Refer to SSAP No. 53—Property-Casualty Contracts – Premiums for accounting guidance.

Column 4 – Premiums Earned During Year

Sum of Lines 13 through 15 should agree with Schedule H, Part 1, Column 1 (Line 2 minus Line 6).

Line 13 – Should agree with Schedule H, Part 1, Line 2 – Line 6, Column 3.

Line 14 – Should agree with Schedule H, Part 1, Line 2 – Line 6, Column 5.

Line 15 – Should agree with Schedule H, Part 1, Line 2 – Line 6, Columns 7 through 17.

Line 35 – Should agree with Page 4, Line 1, Column 1. Line 13.1 – Comprehensive (Hospital and Medical) Individual

Column 4 should agree with Schedule H, Part 1, Line 2 minus Line 6, Column 3. Line 13.2 – Comprehensive (Hospital and Medical) Group

Column 4 should agree with Schedule H, Part 1, Line 2 minus Line 6, Column 5. Line 14 – Credit A&H (Group and Individual)

Column 4 should agree with Schedule H, Part 1, Line 2 minus Line 6, Column 19. Line 15.1 – Vision Only

Column 4 should agree with Schedule H, Part 1, Line 2 minus Line 6, Column 9. Line 15.2 – Dental Only

Column 4 should agree with Schedule H, Part 1, Line 2 minus Line 6, Column 11.

Attachment E


Line 15.3 – Disability Income

Column 4 should agree with Schedule H, Part 1, Line 2 minus Line 6, Column 21. Line 15.4 – Medicare Supplement

Column 4 should agree with Schedule H, Part 1, Line 2 minus Line 6, Column 7. Line 15.5 – Medicaid Title XIX

Column 4 should agree with Schedule H, Part 1, Line 2 minus Line 6, Column 17. Line 15.6 – Medicare Title XVIII

Column 4 should agree with Schedule H, Part 1, Line 2 minus Line 6, Column 15. Line 15.7 – Long-Term Care

Column 4 should agree with Schedule H, Part 1, Line 2 minus Line 6, Column 23. Line 15.8 – Federal Employees Health Benefits Plan Premium

Column 4 should agree with Schedule H, Part 1, Line 2 minus Line 6, Column 13. Line 15.9 – Other Health

Column 4 should agree with Schedule H, Part 1, Line 2 minus Line 6, Column 25.

Attachment E



PART 1A – RECAPITULATION OF ALL PREMIUMS


Line 15 should include additional reserves on noncancelable accident and health policies. Refer to SSAP No. 54R—Individual and Group Accident and Health Contracts for accounting guidance. Attach to the annual statement a description of the methods used in computing this reserve for each type of coverage for which a reserve is held. Line 13.1 – Comprehensive (Hospital and Medical) Individual Group Accident and Health

Column 1 plus Column 2 should agree with Schedule H, Part 2, Line A1, Column 2. Line 13.2 – Comprehensive (Hospital and Medical) Group

Column 1 plus Column 2 should agree with Schedule H, Part 2, Line A1, Column 3. Line 14 – Credit Accident and Health

Column 1 plus Column 2 should agree with Schedule H, Part 2, Line A1, Column 310.

Column 4 should agree with Schedule H, Part 2, Line A3, Column 310.

Include: Business not exceeding 120 months duration. Line 15.1 – Vision Only Other Accident and Health

Column 1 plus Column 2 should agree with Schedule H, Part 2, Line A1, Columns 4 through 95. Line 15.2 – Dental Only

Column 1 plus Column 2 should agree with Schedule H, Part 2, Line A1, Columns 6. Line 15.3 – Disability Income

Column 1 plus Column 2 should agree with Schedule H, Part 2, Line A1, Columns 11. Line 15.4 – Medicare Supplement

Column 1 plus Column 2 should agree with Schedule H, Part 2, Line A1, Columns 4. Line 15.5 – Medicaid Title XIX

Column 1 plus Column 2 should agree with Schedule H, Part 2, Line A1, Columns 9. Line 15.6 – Medicare Title XVIII

Column 1 plus Column 2 should agree with Schedule H, Part 2, Line A1, Columns 8. Line 15.7 – Long-Term Care

Column 1 plus Column 2 should agree with Schedule H, Part 2, Line A1, Columns 12.

Attachment E


Line 15.8 – Federal Employees Health Benefits Plan Premium

Column 1 plus Column 2 should agree with Schedule H, Part 2, Line A1, Columns 7. Line 15.9 – Other Health

Column 1 plus Column 2 should agree with Schedule H, Part 2, Line A1, Columns 13. Line 34 – Aggregate Write-ins for Other Lines of Business

Enter the total of the write-ins listed in schedule Details of Write-ins Aggregated at Line 34 for Other Lines of Business.

Line 36 – Accrued Retrospective Premiums Based on Experience

Include: Accrued return retrospective premiums required by policy terms or law.

Accrued MLR Rebates per the Public Health Service Act.

Retrospective Premium Adjustment Made Through Earned Premium:

Enter the total gross accrued retrospective debit adjustment based on experience, included as a negative amount in Column 4 if the company accrues for additional retrospective premiums by adjusting earned premiums.

Retrospective Premium Adjustment Made Through Written Premium:

Enter the total gross accrued retrospective credit adjustments based on experience if the company accrues for additional retrospective premiums by adjusting written premiums.

Refer to SSAP No. 66—Retrospectively Rated Contracts. Per SSAP No. 66, retrospective premium adjustments shall be estimated based on the experience to date.

Details of Write-ins Aggregated at Line 34 for Other Lines of Business

List separately each line of business for which there is no pre-printed line on Underwriting and Investment Exhibit, Part 1A.

Attachment E



PART 1B – PREMIUMS WRITTEN Column 1 – Direct Business

Line 35 should agree with Schedule T, Line 59, Column 2. Column 6 – Net Premiums Written

Should agree with Underwriting and Investment Exhibit, Part 1, Column 1, for all lines. Line 13.1 – Comprehensive (Hospital and Medical) Individual Group Accident and Health


Column 4 plus Column 5 should agree with Schedule H, Part 4, Line B1, Column 2.

Column 6 should agree with Schedule H, Part 1, Line 1, Column 3. Line 13.2 – Comprehensive (Hospital and Medical) Group



Column 6 should agree with Schedule H, Part 1, Line 1, Column 5. Line 14 – Credit Accident and Health



Column 6 should agree with Schedule H, Part 1, Line 1, Column 519.


Column 2 plus Column 3 should agree with Schedule H, Part 4, Line A1, Columns 4 through 95.

Column 4 plus Column 5 should agree with Schedule H, Part 4, Line B1, Columns 4 through 95.

Column 6 should agree with Schedule H, Part 1, Line 1, Columns 7 through 179.

Attachment E


Line 15.2 – Dental Only


Column 4 plus Column 5 should agree with Schedule H, Part 4, Line B1, Columns 6.

Column 6 should agree with Schedule H, Part 1, Line 1, Columns 11. Line 15.3 – Disability Income



Column 6 should agree with Schedule H, Part 1, Line 1, Columns 21. Line 15.4 – Medicare Supplement



Column 6 should agree with Schedule H, Part 1, Line 1, Columns 7. Line 15.5 – Medicaid Title XIX



Column 6 should agree with Schedule H, Part 1, Line 1, Columns 17. Line 15.6 – Medicare Title XVIII



Column 6 should agree with Schedule H, Part 1, Line 1, Columns 15. Line 15.7 – Long-Term Care



Column 6 should agree with Schedule H, Part 1, Line 1, Columns 23.

Attachment E


Line 15.8 – Federal Employees Health Benefits Plan Premium



Column 6 should agree with Schedule H, Part 1, Line 1, Columns 13. Line 15.9 – Other Health



Column 6 should agree with Schedule H, Part 1, Line 1, Columns 25. Line 35 – Totals

Column 4 plus Column 5 should agree with Schedule F, Part 3, Column 6, Total multiplied by 1000.

Attachment E



PART 2 – LOSSES PAID AND INCURRED Refer to SSAP No. 55—Unpaid Claims, Losses and Loss Adjustment Expenses for accounting guidance. Column 1 – Losses Paid Less Salvage – Direct Business

Line 35 should agree with Schedule T, Line 59, Column 5.


Column 5 – Net Losses Unpaid Current Year

The amounts reported for the lines in this column should agree with the amounts reported for the identical line in Column 8 of the Underwriting and Investment Exhibit, Part 2A.

Line 35 should agree with Page 3, Line 1, Column 1 and with Underwriting and Investment Exhibit, Part 2A, Line 35, Column 8.

Sum of Lines 13, 14 and 15 should agree with. Schedule H, Part 3, Line 2.1 plus Line 2.2, Column 1


Column 8 – Percentage of Losses Incurred

Percentages by line of business are calculated by dividing Column 7 of Underwriting and Investment Exhibit, Part 2, by Column 4 of Underwriting and Investment Exhibit, Part 1, and then multiplying by 100.

Line 13.1 – Comprehensive (Hospital and Medical) Individual Group Accident and Health

Column 4 should agree with Schedule H, Part 3, Line 1.1 plus Line 1.2, Column 2.


Column 6 should agree with Schedule H, Part 2, Line C2, Column 2.

Column 7 should agree with Schedule H, Part 1, Line 3, Column 3. Line 13.2 – Comprehensive (Hospital and Medical) Group





Attachment E


Line 14 – Credit Accident and Health






Column 4 should agree with Schedule H, Part 3, Line 1.1 plus Line 1.2, Columns 4 through 95.

Column 5 should agree with Schedule H, Part 3, Line 2.1 plus Line 2.2, Columns 4 through 95.

Column 6 should agree with Schedule H, Part 2, Line C2, Columns 4 through 95.

Column 7 should agree with Schedule H, Part 1, Line 3, Columns 7 through 179. Line 15.2 – Dental Only




Column 7 should agree with Schedule H, Part 1, Line 3, Column 11. Line 15.3 – Disability Income




Column 7 should agree with Schedule H, Part 1, Line 3, Column 21. Line 15.4 – Medicare Supplement





Attachment E


Line 15.5 – Medicaid Title XIX




Column 7 should agree with Schedule H, Part 1, Line 3, Column 17. Line 15.6 – Medicare Title XVIII




Column 7 should agree with Schedule H, Part 1, Line 3, Column 15. Line 15.7 – Long-Term Care




Column 7 should agree with Schedule H, Part 1, Line 3, Column 23. Line 15.8 – Federal Employees Health Benefits Plan Premium




Column 7 should agree with Schedule H, Part 1, Line 3, Column 13. Line 15.9 – Other Health




Column 7 should agree with Schedule H, Part 1, Line 3, Column 25. Line 34 – Aggregate Write-ins for Other Lines of Business


Details of Write-ins Aggregated at Line 34 for Other Lines of Business

List separately each line of business for which there is no pre-printed line on Underwriting and Investment Exhibit, Part 2.

Attachment E



PART 2A – UNPAID LOSSES AND LOSS ADJUSTMENT EXPENSES Refer to SSAP No. 55—Unpaid Claims, Losses and Loss Adjustment Expenses for accounting guidance.


Column 7 – Incurred But Not Reported – Reinsurance Ceded

Line 35 (total) should agree with Schedule F, Part 3, Column 11, Total multiplied by 1000. Column 8 – Net Losses Unpaid

Line 13 should agree with Schedule H, Part 2, Line C1, Column 2.

Line 14 should agree with Schedule H, Part 2, Line C1, Column 3.

Line 15 should agree with Schedule H, Part 2, Line C1, Columns 4 through 9.

Line 35 (total) should agree with Page 3, Line 1, Column 1.

Total on Line 35 to agree with Schedule P, Part 1, Summary, Column 35, Total multiplied by 1000. Column 9 – Net Unpaid Loss Adjustment Expenses

Report loss adjustment expenses incurred by the reinsurer.

Line 35 (total) should agree with Page 3, Line 3, Column 1.

Total on Line 35 to agree with Schedule P, Part 1, Summary, Column 36, Total multiplied by 1000. Line 13.1 – Comprehensive (Hospital and Medical) Individual

Column 8 should agree with Schedule H, Part 2, Line C1, Column 2. Line 13.2 – Comprehensive (Hospital and Medical) Group

Column 8 should agree with Schedule H, Part 2, Line C1, Column 3. Line 14 – Credit Accident and Health (Group and Individual)


Include: Business not exceeding 120 months duration. Line 15.1 – Vision Only

Column 8 should agree with Schedule H, Part 2, Line C1, Columns 5.

Attachment E


Line 15.2 – Dental Only

Column 8 should agree with Schedule H, Part 2, Line C1, Columns 6. Line 15.3 – Disability Income

Column 8 should agree with Schedule H, Part 2, Line C1, Columns 11. Line 15.4 – Medicare Supplement

Column 8 should agree with Schedule H, Part 2, Line C1, Columns 4. Line 15.5 – Medicaid Title XIX

Column 8 should agree with Schedule H, Part 2, Line C1, Columns 9. Line 15.6 – Medicare Title XVIII

Column 8 should agree with Schedule H, Part 2, Line C1, Columns 8. Line 15.7 – Long-Term Care

Column 8 should agree with Schedule H, Part 2, Line C1, Columns 12. Line 15.8 – Federal Employees Health Benefits Plan Premium

Column 8 should agree with Schedule H, Part 2, Line C1, Columns 7. Line 15.9 – Other Health

Column 8 should agree with Schedule H, Part 2, Line C1, Columns 13. Line 34 – Aggregate Write-ins for Other Lines of Business


Line 35 – Totals

Columns 1 plus Column 5 should agree with Schedule T, Line 59, Column 7. Details of Write-ins Aggregated at Line 34 for Other Lines of Business

List separately each line of business for which there is no pre-printed line on Underwriting and Investment Exhibit, Part 2A.

Attachment E


ANNUAL STATEMENT BLANK – LIFE\FRATERNAL AND PROPERTY

SCHEDULE H – ACCIDENT AND HEALTH EXHIBIT

PART 1 – ANALYSIS OF UNDERWRITING OPERATIONS

Total Comprehensive (Hospital and Medical) Individual

Comprehensive (Hospital and Medical) Group Medicare Supplement Vision Only Dental Only

Federal Employees Health Benefits Plan Premium

1 2 3 4 5 6 7 8 9 10 11 12 13 14 Amount % Amount % Amount % Amount % Amount % Amount % Amount %

1. Premiums written ................................................................................................................. ...................... xxx ................... xxx ...................... xxx ........................ xxx ......................... xxx ........................ xxx ...................... xxx 2. Premiums earned .................................................................................................................. ...................... xxx ................... xxx ...................... xxx ........................ xxx ......................... xxx ........................ xxx ...................... xxx 3. Incurred claims ..................................................................................................................... ...................... ......... ................... ....... ...................... ........ ........................ ........ ......................... ..... ........................ ...... ...................... ..... 4. Cost containment expenses .................................................................................................. ...................... ......... ................... ....... ...................... ........ ........................ ........ ......................... ..... ........................ ...... ...................... ..... 5. Incurred claims and cost containment expenses (Lines 3 and 4) ......................................... ...................... ......... ................... ....... ...................... ........ ........................ ........ ......................... ..... ........................ ...... ...................... ..... 6. Increase in contract reserves ................................................................................................ ...................... ......... ................... ....... ...................... ........ ........................ ........ ......................... ..... ........................ ...... ...................... ..... 7. Commissions (a) .................................................................................................................. ...................... ......... ................... ....... ...................... ........ ........................ ........ ......................... ..... ........................ ...... ...................... ..... 8. Other general insurance expenses ........................................................................................ ...................... ......... ................... ....... ...................... ........ ........................ ........ ......................... ..... ........................ ...... ...................... ..... 9. Taxes, licenses and fees ....................................................................................................... ...................... ......... ................... ....... ...................... ........ ........................ ........ ......................... ..... ........................ ...... ...................... ..... 10. Total other expenses incurred .............................................................................................. ...................... ......... ................... ....... ...................... ........ ........................ ........ ......................... ..... ........................ ...... ...................... ..... 11. Aggregate write-ins for deductions ...................................................................................... ...................... ......... ................... ....... ...................... ........ ........................ ........ ......................... ..... ........................ ...... ...................... ..... 12. Gain from underwriting before dividends or refunds .......................................................... ...................... ......... ................... ....... ...................... ........ ........................ ........ ......................... ..... ........................ ...... ...................... ..... 13. Dividends or refunds ............................................................................................................ ...................... ......... ................... ....... ...................... ........ ........................ ........ ......................... ..... ........................ ...... ...................... ..... 14. Gain from underwriting after dividends or refunds

DETAILS OF WRITE-INS 1101. .............................................................................................................................................. ......................... ......... ................... ..... ...................... ..... ...................... ..... ....................... ..... ....................... ..... ..................... ..... 1102. .............................................................................................................................................. ......................... ......... ................... ..... ...................... ..... ...................... ..... ....................... ..... ....................... ..... ..................... ..... 1103. .............................................................................................................................................. ......................... ......... ................... ..... ...................... ..... ...................... ..... ....................... ..... ....................... ..... ..................... ..... 1198. Summary of remaining write-ins for Line 11 from overflow page ..................................... ......................... ......... ................... ..... ...................... ..... ...................... ..... ....................... ..... ....................... ..... ..................... ..... 1199. Total (Lines 1101 through 1103 plus 1198) (Line 11 above)

Medicare Title XVIII Medicaid Title XIX Credit A&H Disability Income Long-Term Care Other Health 15 16 17 18 19 20 21 22 23 24 25 26 Amount % Amount % Amount % Amount % Amount % Amount %

1. Premiums written ................................................................................................................. ...................... xxx ................... xxx ...................... xxx ........................ xxx ......................... xxx ........................ xxx 2. Premiums earned .................................................................................................................. ...................... xxx ................... xxx ...................... xxx ........................ xxx ......................... xxx ........................ xxx 3. Incurred claims ..................................................................................................................... ...................... ......... ................... ....... ...................... ........ ........................ ........ ......................... ..... ........................ ...... 4. Cost containment expenses .................................................................................................. ...................... ......... ................... ....... ...................... ........ ........................ ........ ......................... ..... ........................ ...... 5. Incurred claims and cost containment expenses (Lines 3 and 4) ......................................... ...................... ......... ................... ....... ...................... ........ ........................ ........ ......................... ..... ........................ ...... 6. Increase in contract reserves ................................................................................................ ...................... ......... ................... ....... ...................... ........ ........................ ........ ......................... ..... ........................ ...... 7. Commissions (a) .................................................................................................................. ...................... ......... ................... ....... ...................... ........ ........................ ........ ......................... ..... ........................ ...... 8. Other general insurance expenses ........................................................................................ ...................... ......... ................... ....... ...................... ........ ........................ ........ ......................... ..... ........................ ...... 9. Taxes, licenses and fees ....................................................................................................... ...................... ......... ................... ....... ...................... ........ ........................ ........ ......................... ..... ........................ ...... 10. Total other expenses incurred .............................................................................................. ...................... ......... ................... ....... ...................... ........ ........................ ........ ......................... ..... ........................ ...... 11. Aggregate write-ins for deductions ...................................................................................... ...................... ......... ................... ....... ...................... ........ ........................ ........ ......................... ..... ........................ ...... 12. Gain from underwriting before dividends or refunds .......................................................... ...................... ......... ................... ....... ...................... ........ ........................ ........ ......................... ..... ........................ ...... 13. Dividends or refunds ............................................................................................................ ...................... ......... ................... ....... ...................... ........ ........................ ........ ......................... ..... ........................ ...... 14. Gain from underwriting after dividends or refunds

DETAILS OF WRITE-INS 1101. .............................................................................................................................................. ......................... ......... ................... ..... ...................... ..... ...................... ..... ....................... ..... ....................... ..... 1102. .............................................................................................................................................. ......................... ......... ................... ..... ...................... ..... ...................... ..... ....................... ..... ....................... ..... 1103. .............................................................................................................................................. ......................... ......... ................... ..... ...................... ..... ...................... ..... ....................... ..... ....................... ..... 1198. Summary of remaining write-ins for Line 11 from overflow page ..................................... ......................... ......... ................... ..... ...................... ..... ...................... ..... ....................... ..... ....................... ..... 1199. Total (Lines 1101 through 1103 plus 1198) (Line 11 above)

(a) Includes $............................... reported as "Contract, membership and other fees retained by agents."

Attachment E


SCHEDULE H – ACCIDENT AND HEALTH EXHIBIT

Other Individual Contracts

Total Group Accident

and Health Credit A&H (Group

and Individual) Collectively Renewable

Non-Cancelable

Guaranteed Renewable

Non-Renewable for Stated Reasons Only

Other Accident Only

All Other

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Amount % Amount % Amount % Amount % Amount % Amount % Amount % Amount % Amount %

PART 1 – ANALYSIS OF UNDERWRITING OPERATIONS 1. Premiums written ............................. 2. Premiums earned .............................. 3. Incurred claims ................................. 4. Cost containment expenses .............. 5. Incurred claims and cost

containment expenses (Lines 3 and 4) ................................................

6. Increase in contract reserves............. 7. Commissions (a) ............................... 8. Other general insurance expenses .... 9. Taxes, licenses and fees ................... 10. Total other expenses incurred .......... 11. Aggregate write-ins for deductions ..................................................... 12. Gain from underwriting before dividends or refunds ......................... 13. Dividends or refunds ........................ 14. Gain from underwriting after dividends or refunds

...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ......................

xxx xxx

.......... .......... .......... .......... .......... .......... .......... .......... .......... .......... ..........

.................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... ....................

xxx xxx ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ......

...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ......................

xxx xxx

........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........

........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................

xxx xxx ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... .......

......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... .........................

xxx xxx ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... .....

........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................

xxx xxx ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ......

..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... .....................

xxx xxx ...... ...... ...... ...... ...... ...... ...... ...... ...... ..... .....

......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... .........................

xxx xxx

...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ......

....................

....................

....................

.................... .................... .................... .................... .................... .................... .................... .................... .................... ....................

xxx xxx

....... ....... ....... ....... ....... ....... ....... ....... ....... ....... .......

DETAILS OF WRITE-INS 1101. ..........................................................1102. ..........................................................1103. ..........................................................1198. Summary of remaining write-ins

for Line 11 from overflow page .......1199. Total (Lines 1101 through 1103

plus 1198) (Line 11 above)

...................... ...................... ...................... ......................

.......... .......... .......... ..........

.................... .................... .................... ....................

...... ...... ...... ......

...................... ...................... ...................... ......................

........ ........ ........ ........

........................ ........................ ........................ .......................

....... ....... ....... .......

......................... ......................... ......................... .........................

...... ...... ...... ......

....................... ....................... ....................... .......................

...... ...... ...... ......

.................... ....................

..... ..... ..... .....

......................... ......................... ......................... .........................

...... ...... ...... ......

................... ................... ................... ...................

....... ....... ....... .......

(a) Includes $............................... reported as "Contract, membership and other fees retained by agents."

Attachment E


SCHEDULE H – ACCIDENT AND HEALTH EXHIBIT (Continued)


1 2 3 4 5 6 7 8 9 10 11 12 13

Total

Comprehensive (Hospital and

Medical) Individual


Medical) Group Medicare


Dental Only

Federal Employees

Health Benefits Plan Premium

Medicare Title

XVIII Medicaid Title XIX

Credit A&H

Disability Income

Long-Term Care

Other Health

A. Premium Reserves: 1. Unearned premiums ............................................................ .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... .................... 2. Advance premiums .............................................................. .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... .................... 3. Reserve for rate credits ........................................................ .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... .................... 4. Total premium reserves, current year .................................. .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... .................... 5. Total premium reserves, prior year ..................................... .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... .................... 6. Increase in total premium reserves B. Contract Reserves: 1. Additional reserves (a) ........................................................ .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... .................... 2. Reserve for future contingent benefits ................................ .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... .................... 3. Total contract reserves, current year ................................... .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... .................... 4. Total contract reserves, prior year ....................................... .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... .................... 5. Increase in contract reserves C. Claim Reserves and Liabilities: 1. Total current year ................................................................ .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... .................... 2. Total prior year .................................................................... .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... .................... 3. Increase

PART 3 – TEST OF PRIOR YEAR'S CLAIM RESERVES AND LIABILITIES

1 2 3 4 5 6 7 8 9 10 11 12 13

Total


Medical) Individual




Dental Only

Federal Employees


Medicare Title


Credit A&H

Disability Income

Long-Term Care

Other Health

1. Claim paid during the year: 1.1 On claims incurred prior to current year ............................. .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... .................... 1.2 On claims incurred during current year ............................... .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... ....................2. Claim reserves and liabilities, December 31, current year: .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... .................... 2.1 On claims incurred prior to current year ............................. .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... .................... 2.2 On claims incurred during current year ............................... .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... ....................3. Test: .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... .................... 3.1 Line 1.1 and 2.1 ................................................................... .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... .................... 3.2 Claim reserves and liabilities, December 31, prior year ...... .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... .................... 3.3 Line 3.1 minus Line 3.2

PART 4 – REINSURANCE

1 2 3 4 5 6 7 8 9 10 11 12 13

Total


Medical) Individual




Dental Only

Federal Employees


Medicare Title


Credit A&H

Disability Income

Long-Term Care

Other Health

A. Reinsurance Assumed: 1. Premiums written ................................................................ .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... .................... 2. Premiums earned ................................................................. .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... .................... 3. Incurred claims .................................................................... .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... .................... 4. Commissions B. Reinsurance Ceded: 1. Premiums written ................................................................ .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... .................... 2. Premiums earned ................................................................. .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... .................... 3. Incurred claims .................................................................... .................... ............................... .............................. ...................... .................... .................... ............................ .................... .................... .................... .................... .................... .................... 4. Commissions

(a) Includes $ ................ premium deficiency reserve.

Attachment E


SCHEDULE H – ACCIDENT AND HEALTH EXHIBIT (Continued)

1 2 3 4 Other Individual Contracts

Total

Group

Accident and Health

Credit A&H (Group and Individual)

Collectively Renewable

5

Non-Cancelable

6

Guaranteed Renewable

7 Non-Renewable for

Stated Reasons Only

8

Other Accident Only

9

All Other

PART 2 – RESERVES AND LIABILITIES A. Premium Reserves: 1. Unearned premiums .......................................................................... 2. Advance premiums ............................................................................ 3. Reserve for rate credits ...................................................................... 4. Total premium reserves, current year ................................................ 5. Total premium reserves, prior year ................................................... 6. Increase in total premium reserves

............................... ............................... ............................... ............................... ...............................

.............................. .............................. .............................. .............................. ..............................

.............................. .............................. .............................. .............................. ..............................

............................... ............................... ............................... ............................... ...............................

............................... ............................... ............................... ............................... ...............................

............................... ............................... ............................... ............................... ...............................

.............................. .............................. .............................. .............................. ..............................

............................... ............................... ............................... ............................... ...............................

.............................. .............................. .............................. .............................. ..............................

B. Contract Reserves: 1. Additional reserves (a) ...................................................................... 2. Reserve for future contingent benefits .............................................. 3. Total contract reserves, current year ................................................. 4. Total contract reserves, prior year ..................................................... 5. Increase in contract reserves

............................... ............................... ............................... ...............................

.............................. .............................. .............................. ..............................

.............................. .............................. .............................. ..............................

............................... ............................... ............................... ...............................

............................... ............................... ............................... ...............................

............................... ............................... ............................... ...............................

.............................. .............................. .............................. ..............................

............................... ............................... ............................... ...............................

.............................. .............................. .............................. ..............................

C. Claim Reserves and Liabilities: 1. Total current year .............................................................................. 2. Total prior year .................................................................................. 3. Increase

............................... ...............................

.............................. ..............................

.............................. ..............................

............................... ...............................

............................... ...............................

............................... ...............................

.............................. ..............................

............................... ...............................

.............................. ..............................

PART 3 – TEST OF PRIOR YEAR'S CLAIM RESERVES AND LIABILITIES 1. Claim paid during the year: 1.1 On claims incurred prior to current year ........................................... 1.2 On claims incurred during current year .............................................2. Claim reserves and liabilities, December 31, current year: 2.1 On claims incurred prior to current year ........................................... 2.2 On claims incurred during current year .............................................3. Test: 3.1 Line 1.1 and 2.1 ................................................................................. 3.2 Claim reserves and liabilities, December 31, prior year ................... 3.3 Line 3.1 minus Line 3.2

............................... ............................... ............................... ............................... ............................... ...............................

.............................. .............................. .............................. .............................. .............................. ..............................

.............................. .............................. .............................. .............................. .............................. ..............................

............................... ............................... ............................... ............................... ............................... ...............................

............................... ............................... ............................... ............................... ............................... ...............................

............................... ............................... ............................... ............................... ............................... ...............................

.............................. .............................. .............................. .............................. .............................. ..............................

............................... ............................... ............................... ............................... ............................... ...............................

.............................. .............................. .............................. .............................. .............................. ..............................

PART 4 – REINSURANCE A. Reinsurance Assumed: 1. Premiums written .............................................................................. 2. Premiums earned ............................................................................... 3. Incurred claims .................................................................................. 4. Commissions

............................... ............................... ...............................

.............................. .............................. ..............................

.............................. .............................. ..............................

............................... ............................... ...............................

............................... ............................... ...............................

............................... ............................... ...............................

.............................. .............................. ..............................

............................... ............................... ...............................

.............................. .............................. ..............................

B. Reinsurance Ceded: 1. Premiums written .............................................................................. 2. Premiums earned ............................................................................... 3. Incurred claims .................................................................................. 4. Commissions

............................... ............................... ...............................

.............................. .............................. ..............................

.............................. .............................. ..............................

............................... ............................... ...............................

............................... ............................... ...............................

............................... ............................... ...............................

.............................. .............................. ..............................

............................... ............................... ...............................

.............................. .............................. ..............................

(a) Includes $ ................ premium deficiency reserve.

Attachment E


SCHEDULE H – PART 5 – HEALTH CLAIMS

1 2 3 4 5 6 7 8 9 10 11 12 13


Medical) Individual



Supplement

1 Medical Vision Only

2 Dental Only

3 Other

Federal Employees

Health Benefits

Plan Premium

Medicare Title


Credit A&H

Disability Income

Long-Term Care

Other Health

4 Total

A. Direct: 1. Incurred Claims ............................................................. ................................ .............................. ...................... .................... .................... ......................... .................... .................... .................... .................... .................... .................... .................... 2. Beginning claim reserves and liabilities ........................ ................................ .............................. ...................... .................... .................... ......................... .................... .................... .................... .................... .................... .................... .................... 3. Ending claim reserves and liabilities ............................. ................................ .............................. ...................... .................... .................... ......................... .................... .................... .................... .................... .................... .................... .................... 4. Claims paid .................................................................... ................................ .............................. ...................... .................... .................... ......................... .................... .................... .................... .................... .................... .................... .................... B. Assumed Reinsurance: 15. Incurred Claims ............................................................. ................................ .............................. ...................... .................... .................... ......................... .................... .................... .................... .................... .................... .................... .................... 26. Beginning claim reserves and liabilities ........................ ................................ .............................. ...................... .................... .................... ......................... .................... .................... .................... .................... .................... .................... .................... 37. Ending claim reserves and liabilities ............................. ................................ .............................. ...................... .................... .................... ......................... .................... .................... .................... .................... .................... .................... .................... 48. Claims paid .................................................................... ................................ .............................. ...................... .................... .................... ......................... .................... .................... .................... .................... .................... .................... .................... C. Ceded Reinsurance: 19. Incurred Claims ............................................................. ................................ .............................. ...................... .................... .................... ......................... .................... .................... .................... .................... .................... .................... .................... 210. Beginning claim reserves and liabilities ........................ ................................ .............................. ...................... .................... .................... ......................... .................... .................... .................... .................... .................... .................... .................... 311. Ending claim reserves and liabilities ............................. ................................ .............................. ...................... .................... .................... ......................... .................... .................... .................... .................... .................... .................... .................... 412. Claims paid .................................................................... ................................ .............................. ...................... .................... .................... ......................... .................... .................... .................... .................... .................... .................... .................... D. Net: 113. Incurred Claims ............................................................. ................................ .............................. ...................... .................... .................... ......................... .................... .................... .................... .................... .................... .................... .................... 214. Beginning claim reserves and liabilities ........................ ................................ .............................. ...................... .................... .................... ......................... .................... .................... .................... .................... .................... .................... .................... 315. Ending claim reserves and liabilities ............................. ................................ .............................. ...................... .................... .................... ......................... .................... .................... .................... .................... .................... .................... .................... 416. Claims paid .................................................................... ................................ .............................. ...................... .................... .................... ......................... .................... .................... .................... .................... .................... .................... .................... E. Net Incurred Claims and Cost Containment Expenses: 117. Incurred claims and cost containment expenses............ ................................ .............................. ...................... .................... .................... ......................... .................... .................... .................... .................... .................... .................... .................... 218. Beginning reserves and liabilities ................................. ................................ .............................. ...................... .................... .................... ......................... .................... .................... .................... .................... .................... .................... .................... 319. Ending reserves and liabilities ....................................... ................................ .............................. ...................... .................... .................... ......................... .................... .................... .................... .................... .................... .................... .................... 420. Paid claims and cost containment expenses

W:\QA\BlanksProposals\2021-14BWG_Modified.doc

Attachment E



Attachment F




DATE: 10/04/2021

CONTACT PERSON:

TELEPHONE:


NAME: Dale Bruggeman

TITLE: Chair SAPWG

AFFILIATION: Ohio Department of Insurance

ADDRESS: 50W. Town St., 3rd Fl., Ste. 300

Columbus, OH 43215




DISPOSITION [ ] Rejected For Public Comment [ ] Referred To Another NAIC Group [ ] Received For Public Comment [ ] Adopted Date [ ] Rejected Date [ ] Deferred Date [ ] Other (Specify)


[ X ] ANNUAL STATEMENT [ ] INSTRUCTIONS [ X ] CROSSCHECKS [ ] QUARTERLY STATEMENT [ X ] BLANK

[ X ] Life, Accident & Health/Fraternal [ ] Separate Accounts [ ] Title [ ] Property/Casualty [ ] Protected Cell [ ] Other _______________________ [ ] Health [ X ] Health (Life Supplement)


IDENTIFICATION OF ITEM(S) TO CHANGE Add a footnote to Exhibit 7 in the Life/Fraternal Statement and the Health Statement (Life Supplement) to capture amount of FHLB Funding Agreements reported in Columns 1 through 6 of the exhibit.

REASON, JUSTIFICATION FOR AND/OR BENEFIT OF CHANGE** The purpose of this proposal is to provide regulators the amount of FHLB Funding Agreements in the individual columns of Exhibit 7. (2021-16 SAPWG)


Attachment F


ANNUAL STATEMENT BLANK – LIFE/FRATERNAL AND HEALTH (LIFE SUPPLEMENT)

EXHIBIT 7 – DEPOSIT-TYPE CONTRACTS

1 2 3 4 5 6

Total

Guaranteed Interest

Contracts Annuities Certain

Supplemental Contracts

Dividend Accumulations

or Refunds

Premium and Other

Deposit Funds 1. Balance at the beginning of the year before reinsurance ......................................................... .................................. ................................. ................................. ................................ .................................. ............................... 2. Deposits received during the year ............................................................................................ .................................. ................................. ................................. ................................ .................................. ............................... 3. Investment earnings credited to the account ............................................................................ .................................. ................................. ................................. ................................ .................................. ............................... 4. Other net change in reserves .................................................................................................... .................................. ................................. ................................. ................................ .................................. ............................... 5. Fees and other charges assessed .............................................................................................. .................................. ................................. ................................. ................................ .................................. ............................... 6. Surrender charges ..................................................................................................................... .................................. ................................. ................................. ................................ .................................. ............................... 7. Net surrender or withdrawal payments .................................................................................... .................................. ................................. ................................. ................................ .................................. ............................... 8. Other net transfers to or (from) Separate Accounts ................................................................. .................................. ................................. ................................. ................................ .................................. ............................... 9. Balance at the end of current year before reinsurance (a) (Lines 1+2+3+4-5-6-7-8) ............. .................................. ................................. ................................. ................................ .................................. ............................... 10. Reinsurance balance at the beginning of the year .................................................................... .................................. ................................. ................................. ................................ .................................. ............................... 11. Net change in reinsurance assumed ......................................................................................... .................................. ................................. ................................. ................................ .................................. ............................... 12. Net change in reinsurance ceded .............................................................................................. .................................. ................................. ................................. ................................ .................................. ............................... 13. Reinsurance balance at the end of the year (Lines 10+11-12)................................................. .................................. ................................. ................................. ................................ .................................. ............................... 14. Net balance at the end of current year after reinsurance (Lines 9+13)

(a) FHLB Funding Agreements

1. Reported as a GICs (captured in column 2): ........................................................................................................ $____________

2. Reported as an Annuities Certain (captured in column 3): .................................................................................. $____________

3. Reported as Supplemental Contracts (captured in column 4): ............................................................................ $____________

4. Reported as Dividend Accumulations or Refunds (captured in column 5) .......................................................... $____________

5. Issued as Premium or Other Deposit Funds (captured in column 6): .................................................................. $____________

6. Total Issued as Deposit-Type Contracts (captured in column 1): (Sum of Lines 1 through 6) ........................... $____________


Attachment G




DATE: 10/19/2021

CONTACT PERSON:

TELEPHONE:



TITLE: Chair SAPWG



Columbus, OH 43215






[ X ] ANNUAL STATEMENT [ X ] INSTRUCTIONS [ X ] CROSSCHECKS [ ] QUARTERLY STATEMENT [ ] BLANK

[ X ] Life, Accident & Health/Fraternal [ ] Separate Accounts [ X ] Title [ X ] Property/Casualty [ ] Protected Cell [ ] Other _______________________ [ X ] Health [ ] Health (Life Supplement)


IDENTIFICATION OF ITEM(S) TO CHANGE

***See next page for details***


***See next page for details***


Attachment G


IDENTIFICATION OF ITEM(S) TO CHANGE Note 9 – Income Taxes:

Modify the instructions for 9C to eliminate the instruction for adding additional lines for DTA and DTL components to the PDF/printed version of the notes not specifically detailed in the illustration that are greater than 5% to bring in line with the data capture element of the note that can’t accommodate variable lines.

Add formulas for calculation of total and subtotal on the illustration for 9C that are not already present.

Note 15 – Leases:

Modify the illustrations to add a “Thereafter” line.

Add formula for “Total” line.

REASON, JUSTIFICATION FOR AND/OR BENEFIT OF CHANGE** For Note 9 – Income Taxes, address differences between the PDF reporting of Note 9C and the data capture element of the disclosure. The data capture element has a single “Other” line for DTA and DTL components where the instructions for 9C asks that additional lines be added to the illustration for additional components over 5% in the PDF document. The additional lines on the PDF were intended to be temporary to identify if there were other specific lines needed to be added based on what companies were reporting as additional lines on the PDF. With no additional items identified to be added the instruction for adding these lines is being removed. The proposal also specifically clarifies calculation of total and subtotal lines where that calculation has not already been provided for clarification. For Note 15 – Leases, there should have been a line for aggregating the amounts for the remaining years after the five years specifically shown in the illustration. This proposal adds those lines as Line 6 – Thereafter. In addition, formula for calculating the total line has been added to the illustration for clarification.

Attachment G


ANNUAL STATEMENT INSTRUCTIONS – LIFE\FRATERNAL, HEALTH, PROPERTY AND TITLE

NOTES TO FINANCIAL STATEMENTS


9. Income Taxes

Instruction:


C. Disclose the significant components of income taxes incurred (i.e., current income tax expenses) and the changes in DTAs and DTLs. These components would include, for example:

Current tax expense or benefit;

The change in DTAs and DTLs (exclusive of the effects of other components listed below);

Investment tax credits;

The benefits of operating loss carry forwards;

Adjustments of a DTA or DTL for enacted changes in tax laws or rates or a change in the tax status of

the reporting entity; and

Adjustments to gross deferred tax assets because of a change in circumstances that causes a change in judgment about the realizability of the related deferred tax asset, and the reason for the adjustment and change in judgment.

NOTE: The illustration below for this disclosure reflects the setup for the data capture of the electronic

notes. Reporting entities should disclose those items included as “Other” (Lines 2a13, 2e4, 3a5 and 3b3) as additional lines for those items greater than 5% in the printed/PDF filing document.


Attachment G


THIS EXACT FORMAT MUST BE USED IN THE PREPARATION OF THIS NOTE FOR THE TABLE BELOW. REPORTING ENTITIES ARE NOT PRECLUDED FROM PROVIDING CLARIFYING DISCLOSURE BEFORE OR AFTER THIS ILLUSTRATION.

C. Current income taxes incurred consist of the following major components:

(1)

12/31/2021

(2)

12/31/2020

(3)

(Col 1-2) Change

1. Current Income Tax

(a) Federal $ ___________ $ ___________ $ ___________ (b) Foreign $ ___________ $ ___________ $ ___________ (c) Subtotal (1a+1b) $ ___________ $ ___________ $ ___________ (d) Federal income tax on net capital gains $ ___________ $ ___________ $ ___________ (e) Utilization of capital loss carry-forwards $ ___________ $ ___________ $ ___________ (f) Other $ ___________ $ ___________ $ ___________ (g) Federal and foreign income taxes incurred (1c+1d+1e+1f) $ ___________ $ ___________ $ ___________ $ ___________ $ ___________ $ ___________

2.. Deferred Tax Assets:

(a) Ordinary

(1) Discounting of unpaid losses $ ___________ $ ___________ $ ___________ (2) Unearned premium reserve $ ___________ $ ___________ $ ___________ (3) Policyholder reserves $ ___________ $ ___________ $ ___________ (4) Investments $ ___________ $ ___________ $ ___________ (5) Deferred acquisition costs $ ___________ $ ___________ $ ___________ (6) Policyholder dividends accrual $ ___________ $ ___________ $ ___________ (7) Fixed assets $ ___________ $ ___________ $ ___________ (8) Compensation and benefits accrual $ ___________ $ ___________ $ ___________ (9) Pension accrual $ ___________ $ ___________ $ ___________ (10) Receivables – nonadmitted $ ___________ $ ___________ $ ___________ (11) Net operating loss carry-forward $ ___________ $ ___________ $ ___________ (12) Tax credit carry-forward $ ___________ $ ___________ $ ___________ (13) Other (including items <5% of total ordinary tax assets) $ ___________ $ ___________ $ ___________ (99) Subtotal (sum of 2a1 through 2a13) $ ___________ $ ___________ $ ___________

(b) Statutory valuation allowance adjustment $ ___________ $ ___________ $ ___________ (c) Nonadmitted $ ___________ $ ___________ $ ___________

(d) Admitted ordinary deferred tax assets (2a99 – 2b – 2c) $ ___________ $ ___________ $ ___________

(e) Capital:

(1) Investments $ ___________ $ ___________ $ ___________ (2) Net capital loss carry-forward $ ___________ $ ___________ $ ___________ (3) Real estate $ ___________ $ ___________ $ ___________ (4) Other (including items <5% of total capital tax assets) $ ___________ $ ___________ $ ___________ (99) Subtotal (2e1+2e2+2e3+2e4) $ ___________ $ ___________ $ ___________

(f) Statutory valuation allowance adjustment $ ___________ $ ___________ $ ___________ (g) Nonadmitted $ ___________ $ ___________ $ ___________

(h) Admitted capital deferred tax assets (2e99 – 2f – 2g) $ ___________ $ ___________ $ ___________

(i) Admitted deferred tax assets (2d + 2h) $ ___________ $ ___________ $ ___________

3. Deferred Tax Liabilities: $ ___________ $ ___________ $ ___________

(a) Ordinary

(1) Investments $ ___________ $ ___________ $ ___________ (2) Fixed assets $ ___________ $ ___________ $ ___________ (3) Deferred and uncollected premium $ ___________ $ ___________ $ ___________ (4) Policyholder reserves $ ___________ $ ___________ $ ___________ (5) Other (including items <5% of total ordinary tax liabilities) $ ___________ $ ___________ $ ___________ (99) Subtotal (3a1+3a2+3a3+3a4) $ ___________ $ ___________ $ ___________

(b) Capital:

(1) Investments $ ___________ $ ___________ $ ___________ (2) Real estate $ ___________ $ ___________ $ ___________ (3) Other (including items <5% of total capital tax liabilities) $ ___________ $ ___________ $ ___________ (99) Subtotal (3b1+3b2+3b3) $ ___________ $ ___________ $ ___________

(c) Deferred tax liabilities (3a99 + 3b99) ___________ ___________ ___________

4. Net deferred tax assets/liabilities (2i – 3c) $ ___________ $ ___________ $ ___________


Attachment G


15. Leases

Instruction:

A. Disclose the following items related to lessee leasing arrangements (refer to SSAP No. 22R—Leases):


(2) For leases having initial or remaining noncancelable lease terms in excess of one year:

a. Future minimum rental payments required as of the date of the latest balance sheet presented, in the aggregate and for each of the five succeeding years.

b. The total of minimum rentals to be received in the future under noncancelable subleases as of

the date of the latest balance sheet presented.


B. When leasing is a significant part of the lessor’s business activities in terms of revenue, net income or assets, disclose the following information with respect to leases:

(1) For operating leases:

a. A general description of the lessor’s leasing arrangements;

b. The cost and carrying amount, if different, of property on lease or held for leasing by major classes of property according to nature or function, and the amount of accumulated depreciation in total as of the date of the latest balance sheet presented;

c. Minimum future rentals on noncancelable leases as of the date of the latest balance sheet

presented, in the aggregate and for each of the five succeeding years; and

d. Total contingent rentals included in income for each period for which an income statement is presented.

(2) For leveraged leases:

a. A description of the terms including the pretax income from the leveraged leases. For purposes of presenting the investment in a leveraged lease in the lessor’s balance sheet, the amount of related deferred taxes shall be presented separately (from the remainder of the net investment);

b. Separate presentation (from each other) shall be made of pretax income from the leveraged

lease, the tax effect of pretax income, and the amount of investment tax credit recognized as income during the period; and

c. When leveraged leasing is a significant part of the lessor’s business activities in terms of

revenue, net income, or assets, the components of the net investment balance in leveraged leases shall be disclosed.

Attachment G


Illustration:

A. Lessee Operating Lease


THIS EXACT FORMAT MUST BE USED IN THE PREPARATION OF THIS NOTE FOR THE TABLE BELOW. REPORTING ENTITIES ARE NOT PRECLUDED FROM PROVIDING CLARIFYING DISCLOSURE BEFORE OR AFTER THIS ILLUSTRATION. (2)

a. At December 31, 20___, the minimum aggregate rental commitments are as follows: Year Ending December 31 Operating Leases

1. 20__ $ ____________

2. 20__ $ ____________

3. 20__ $ ____________

4. 20__ $ ____________

5. 20__ $ ____________

6. Thereafter $ ____________

67. Total (sum of 1 through 7) $ ____________ (3) The company is not involved in any material sales – leaseback transactions.

B. Lessor Leases


THIS EXACT FORMAT MUST BE USED IN THE PREPARATION OF THIS NOTE FOR THE TABLE BELOW. REPORTING ENTITIES ARE NOT PRECLUDED FROM PROVIDING CLARIFYING DISCLOSURE BEFORE OR AFTER THIS ILLUSTRATION.

c. Future minimum lease payment receivables under noncancelable leasing arrangements as of December 31, 20___ are as follows:

Year Ending December 31 Operating Leases

1. 20__ $ ____________

2. 20__ $ ____________

3. 20__ $ ____________

4. 20__ $ ____________

5. 20__ $ ____________

6. Thereafter $ ____________

67. Total (sum of 1 through 7) $ ____________

d. Contingent rentals included in income for the years ended December 31, 20__ and 20__ amounted to $__________ and $__________, respectively. The net investment is classified as real estate.

Attachment G


THIS EXACT FORMAT MUST BE USED IN THE PREPARATION OF THIS NOTE FOR THE TABLE BELOW. REPORTING ENTITIES ARE NOT PRECLUDED FROM PROVIDING CLARIFYING DISCLOSURE BEFORE OR AFTER THIS ILLUSTRATION. (NOTE: THIS DOES NOT INCLUDE THE BEGINNING NARRATIVE.) (2) Leveraged Leases

b. The Company’s investment in leveraged leases relates to equipment used primarily in the transportation industries. The component of net income from leveraged leases at December 31, 20__ and December 31, 20__ were as shown below:

20___ 20___ 1. Income from leveraged leases before income

tax including investment tax credit $ ________ $ _________

2. Less current income tax $ ________ $ _________

3. Net income from leveraged leases (1-2) $ ________ $ _________



Attachment G



Attachment H




DATE: 10/19/2021

CONTACT PERSON:

TELEPHONE:


NAME: Steve Drutz



ADDRESS:







[ X ] Life, Accident & Health/Fraternal [ ] Separate Accounts [ ] Title [ ] Property/Casualty [ ] Protected Cell [ ] Other _______________________ [ X ] Health [ ] Health (Life Supplement)


IDENTIFICATION OF ITEM(S) TO CHANGE

Modify the Analysis of Operations by Lines of Business in the Health Blank to include all of health lines of business included in the Life/Fraternal Analysis of Operations by Lines of Business – Accident and Health. Add instructions for the new columns and adjust the column references. Add the Health Blank Analysis of Operations by Lines of Business as a supplement to the Life/Fraternal Blank with the appropriate instructions and crosschecks. Add crosscheck to the Health Blank Analysis of Operations by Lines of Business to the Life/Fraternal Analysis of Operations by Lines of Business – Accident and Health instructions


The purpose of the proposal is to add the Health Blank Analysis of Operations by Lines of Business as a supplement to the Life\Fraternal Statement to capture data points Health Blank Analysis of Operations by Lines of Business. This will allow regulators to look at revenue and expenses in the same detail as reported on the Heath Analysis of Operations by Lines of Business.

NAIC STAFF COMMENTS Comment on Effective Reporting Date:

Other Comments:

___________________________________________________________________________________________________ ** This section must be completed on all forms. Revised 7/18/2018

Attachment H


ANNUAL STATEMENT INSTRUCTIONS – HEALTH

ANALYSIS OF OPERATIONS BY LINES OF BUSINESS Please refer to the instructions in Statement of Revenues and Expenses for instructions and line descriptions for this Exhibit. Riders/Endorsements/Floaters:

If a rider, endorsement or floater acts like a separate policy with separate premium, deductible and limit, then it is to be recorded on the same line of business as if it were a stand-alone policy regardless of whether it is referred to as a rider, endorsement or floater. If there is no additional premium, separate deductible or limit, the rider, endorsement or floater should be reported on the same line of business as the base policy.

Column 1 – Total

The amounts in this column are to agree with the corresponding amounts reported on Page 4, Column 2.

Column 2 – Comprehensive (Hospital & Medical) – Individual Column 3 – Comprehensive (Hospital & Medical) – Group

Include: Business that provides for medical coverages including hospital, surgical and major medical. Include State Children’s Health Insurance Program (SCHIP) Medicaid Program (Title XXI), risk contracts.

Exclude: Administrative services only (ASO), other non-underwritten business,

administrative services contracts (ASC), federal employees health benefit plan (FEHBP) premiums, Medicare (Title XVIII) and Medicaid (Title XIX) risk contracts, Medicare Supplement, Vision only and Dental only business.

Column 34 – Medicare Supplement

Include: Business reported in the Medicare Supplement Insurance Experience Exhibit of the annual statement.


administrative services contracts (ASC), federal employees health benefit plan (FEHBP) premiums, comprehensive hospital and medical policies, Medicare (Title XVIII) and Medicaid (Title XIX) risk contracts, Vision only and Dental only business.

Column 45 – Dental Only

Include: Policies providing for dental only coverage issued as stand alone dental or as a rider to a medical policy that is not related to the medical policy through premiums, deductibles or out-of-pocket limits.


administrative services contracts (ASC), federal employees health benefit plan (FEHBP) premiums, comprehensive hospital and medical policies, Medicare (Title XVIII) and Medicaid (Title XIX) risk contracts, Medicare Supplement and Vision only business.

}

Attachment H


Column 56 – Vision Only

Include: Policies providing for vision only coverage issued as stand-alone vision or as a rider to a medical policy that is not related to the medical policy through premiums, deductibles or out-of-pocket limits.


administrative services contracts (ASC), federal employees health benefit plan (FEHBP) premiums, comprehensive hospital and medical policies, Medicare (Title XVIII) and Medicaid (Title XIX) risk contract, Medicare Supplement, and Dental only business.

Column 67 – Federal Employees Health Benefits Plans (FEHBP)

Include: Business allocable to the Federal Employees Health Benefits Plan (FEHBP) premium that are exempted from state taxes or other fees by Section 8909(f)(1) of Title 5 of the United States Code.


administrative services contracts (ASC), comprehensive hospital and medical policies, Medicare (Title XVIII) and Medicaid (Title XIX) risk contracts, Medicare Supplement, Vision only and Dental only business.

Column 78 – Title XVIII - Medicare

Include: Business where the reporting entity charges a premium and agrees to cover the full medical costs of Medicare subscribers. Policies providing Medicare Part D Prescription Drug Coverage through a Medicare Advantage product.


administrative services contracts (ASC), federal employees health benefits plan (FEHBP) premiums, comprehensive hospital and medical policies, Medicaid (Title XIX) risk contracts, Medicare Supplement, Vision only and Dental only business. Policies providing stand alone Medicare Part D Prescription Drug Coverage.

Column 89 – Title XIX - Medicaid

Include: Business where the reporting entity charges a premium and agrees to cover the full medical costs of Medicaid subscribers.


administrative services contracts (ASC), federal employees health benefits plan (FEHBP) premiums, comprehensive hospital and medical policies, Medicare (Title XVIII) risk contracts, Medicare Supplement, Vision only and Dental only business.

Column 10 – Credit A&H

Include: Coverage provided to, or offered to, borrowers in connection with a consumer credit transaction where the proceeds are used to repay a debt or an installment loan in the event the consumer is disabled as the result of an accident, including business not exceeding 120 months duration (Group and Individual).

Attachment H


Column 11 – Disability Income

Include: The term ‘disability income’ includes contracts providing disability income coverage, both short-term and long-term.

Column 12 – Long-Term Care

Include: Any insurance policy or rider that provides coverage for not less than twelve (12) consecutive months for each covered person on an expense incurred, indemnity, prepaid or other basis, for one or more necessary or medically necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance or personal care services, provided in a setting other than an acute care unit of a hospital.

A policy or rider that provides for payment of benefits based upon cognitive impairment or the loss of functional capacity.

Column 913 – Other Health

Include: Other health coverages such as stop loss, disability income, long-term care and prescription drug plans and coverages not specifically addressed in any other columns. Policies providing stand alone Medicare Part D Prescription Drug Coverage.

On Line 20, expenses and reimbursements from administrative services only (ASO), other non-underwritten business and administrative services contracts (ASC).

Exclude: Policies providing Medicare Part D Prescription Drug Coverage through a

Medicare Advantage product. Column 1014 – Other Non-health

Include: Life and property/casualty coverages.

Attachment H



HEALTH ANALYSIS OF OPERATIONS BY LINES OF BUSINESS SUPPLEMENT Please refer to the instructions in Statement of Revenues and Expenses for instructions and line descriptions for this Exhibit. Riders/Endorsements/Floaters:


Column 2 – Comprehensive (Hospital & Medical) – Individual Column 3 – Comprehensive (Hospital & Medical) – Group

Include: Business that provides for medical coverages including hospital, surgical and major medical. Include State Children’s Health Insurance Program (SCHIP) Medicaid Program (Title XXI), risk contracts.


administrative services contracts (ASC), federal employees health benefit plan (FEHBP) premiums, Medicare (Title XVIII) and Medicaid (Title XIX) risk contracts, Medicare Supplement, Vision only and Dental only business.




administrative services contracts (ASC), federal employees health benefit plan (FEHBP) premiums, comprehensive hospital and medical policies, Medicare (Title XVIII) and Medicaid (Title XIX) risk contracts, Vision only and Dental only business.

Column 5 – Dental Only

Include: Policies providing for dental only coverage issued as stand alone dental or as a rider to a medical policy that is not related to the medical policy through premiums, deductibles or out-of-pocket limits.


administrative services contracts (ASC), federal employees health benefit plan (FEHBP) premiums, comprehensive hospital and medical policies, Medicare (Title XVIII) and Medicaid (Title XIX) risk contracts, Medicare Supplement and Vision only business.

}

Attachment H


Column 6 – Vision Only

Include: Policies providing for vision only coverage issued as stand-alone vision or as a rider to a medical policy that is not related to the medical policy through premiums, deductibles or out-of-pocket limits.


administrative services contracts (ASC), federal employees health benefit plan (FEHBP) premiums, comprehensive hospital and medical policies, Medicare (Title XVIII) and Medicaid (Title XIX) risk contract, Medicare Supplement, and Dental only business.

Column 7 – Federal Employees Health Benefits Plans (FEHBP)

Include: Business allocable to the Federal Employees Health Benefits Plan (FEHBP) premium that are exempted from state taxes or other fees by Section 8909(f)(1) of Title 5 of the United States Code.


administrative services contracts (ASC), comprehensive hospital and medical policies, Medicare (Title XVIII) and Medicaid (Title XIX) risk contracts, Medicare Supplement, Vision only and Dental only business.

Column 8 – Title XVIII - Medicare

Include: Business where the reporting entity charges a premium and agrees to cover the full medical costs of Medicare subscribers. Policies providing Medicare Part D Prescription Drug Coverage through a Medicare Advantage product.


administrative services contracts (ASC), federal employees health benefits plan (FEHBP) premiums, comprehensive hospital and medical policies, Medicaid (Title XIX) risk contracts, Medicare Supplement, Vision only and Dental only business. Policies providing stand alone Medicare Part D Prescription Drug Coverage.

Column 9 – Title XIX - Medicaid

Include: Business where the reporting entity charges a premium and agrees to cover the full medical costs of Medicaid subscribers.


administrative services contracts (ASC), federal employees health benefits plan (FEHBP) premiums, comprehensive hospital and medical policies, Medicare (Title XVIII) risk contracts, Medicare Supplement, Vision only and Dental only business.

Column 10 – Credit A&H


Attachment H


Column 11 – Disability Income


Column 12 – Long-Term Care



Column 13 – Other Health

Include: Other health coverages such as stop loss and prescription drug plans and coverages not specifically addressed in any other columns. Policies providing stand alone Medicare Part D Prescription Drug Coverage.

On Line 20, expenses and reimbursements from administrative services only (ASO), other non-underwritten business and administrative services contracts (ASC).

Exclude: Policies providing Medicare Part D Prescription Drug Coverage through a

Medicare Advantage product. Column 14 – Other Non-health

Include: Life and property/casualty coverages. Line 1 – Net Premium Income

Written premium is defined as the contractually determined amount charged by the reporting entity to the policyholder for the effective period of the contract based on the expectation of risk, policy benefits, and expenses associated with the coverage provided by the terms of the insurance contract. For health contracts without fixed contract periods, premiums written will be equal to the amount collected during the reporting period plus uncollected premiums at the end of the period less uncollected premiums at the beginning of the period.

Include: Accrued return premium adjustments for contracts subject to redetermination.

Attachment H


Line 2 – Change in Unearned Premium Reserves and Reserve for Rate Credits

Exclude: Reserves relating to uninsured plans and the uninsured portion of partially insured plans.

Line 3 – Fee-for-Service (Net of $____ Medical Expenses)

Include: Revenue recognized by the reporting entity for provision of health services to non-members by reporting entity providers and to members through provision of health services excluded from their prepaid benefit packages. Include in the inside amount, the medical expenses associated with fee-for-service business.

Line 4 – Risk Revenue

Include: Amounts charged by the reporting entity as a provider or intermediary for specified medical services (e.g., full professional, dental, radiology, etc.) provided to the policyholders or members of another insurer or reporting entity.

Unlike premiums that are collected from an employer group or individual member, risk revenue is the prepaid (usually on a capitated basis) payment, made by another insurer or reporting entity to the reporting entity in exchange for services to be provided or offered by such organization.

Line 5 – Aggregate Write-ins for Other Health Care Related Revenues

Enter the total of the write-ins listed in schedule Details of Write-ins Aggregated at Line 5 for Other Health Care Related Revenues.

Line 6 – Aggregate Write-ins for Other Non-health Revenues

Enter the total of the write-ins in schedule Details of Write-ins Aggregate at Line 6 for Other Non-health Revenues.

Line 8 – Hospital/Medical Benefits

Include: Expenses for physician services provided under contractual arrangement to the reporting entity.

Salaries, including fringe benefits, paid to physicians for delivery of medical services. Capitation payments by the reporting entity to physicians for delivery of medical services to reporting entity subscribers.

Fees paid by the reporting entity to physicians on a fee-for-service basis for delivery of medical services to reporting entity subscribers. This includes capitated referrals.

Inpatient hospital costs of routine and ancillary services for reporting entity members while confined to an acute care hospital.

Charges for non-reporting entity physician services provided in a hospital are included in this line item only if included as an undefined portion of charges by a hospital to the reporting entity. (If separately itemized or billed, physician charges should be included in outside referrals below.)

The cost of utilizing skilled nursing and intermediate care facilities.

Attachment H


Routine hospital service includes regular room and board (including intensive care units, coronary care units, and other special inpatient hospital units), dietary and nursing services, medical surgical supplies, medical social services, and the use of certain equipment and facilities for which the provider does not customarily make a separate charge.

Ancillary services may also include laboratory, radiology, drugs, delivery room, physical therapy services, other special items and services for which charges are customarily made in addition to a routine service charge.

Skilled nursing facilities are primarily engaged in providing skilled nursing care and related services for patients who require medical or nursing care or rehabilitation service.

Intermediate care facilities are for individuals who do not require the degree of care and treatment that a hospital or skilled nursing-care facility provides, but that do require care and services above the level of room and board.

Report gross of reinsurance. Report net of coordination of benefits, co-payments and subrogation.

Exclude: Expenses for medical personnel time devoted to administrative tasks.

Emergency room and out-of-area hospitalization.


Line 9 – Other Professional Services

Include: Expenses for other professional providers under contractual arrangement to the reporting entity.

Salaries, as well as fringe benefits, paid by the reporting entity to non-physician providers licensed, accredited or certified to perform specified health services, consistent with state law, engaged in the delivery of medical services.

Compensation to personnel engaged in activities in direct support of the provision of medical services. For example, include compensation to pharmacists, dentists, psychologists, optometrists, podiatrists, extenders, nurses, clinical personnel such as ambulance drivers and technicians.

Exclude: Professional services not meeting this definition. Report these services

as administrative expenses. For example, exclude compensation to paraprofessionals, janitors, quality assurance analysts, administrative supervisors, secretaries to medical personnel, and medical record clerks.

Prescription drugs.


Attachment H


Line 10 – Outside Referrals

Include: Expenses for providers not under arrangement with the reporting entity to provide services, such as consultations, or out-of-network providers.

Line 11 – Emergency Room and Out-of-Area

Include: Expenses for other health delivery services including emergency room costs incurred by members for which the reporting entity is responsible and out-of-area service costs for emergency physician and hospital.

In the event a member is admitted to the health care facility immediately after seeking emergency room service, emergency service expenses are reported in this line, the expenses after admission are reported in the hospital/medical line, provided the member is seeking services in the service area. Out-of-area expenses incurred, whether emergency or hospital, are reported in this line.

Line 12 – Prescription Drugs

Include: Expenses for Prescription Drugs and other pharmacy benefits covered by the reporting entity.

Deduct: Pharmaceutical rebates relating to insured plans.

Exclude: Prescription drug charges that are included in a hospital billing which should be

classified as Hospital/Medical Benefits on Line 8. Line 13 – Aggregate Write-ins for Other Hospital and Medical

Include: Other hospital and medical expenses not covered in the other claims accounts. Line 14 – Incentive Pool, Withhold Adjustments and Bonus Amounts

This category is for adjusting the full medical expenses reported by means of both debit and credit entries. For example, report physician withholds forfeited to the reporting entity as a credit entry. Report amounts incurred due to an arrangement whereby the reporting entity agrees to utilization savings with a provider as a debit entry.

Line 16 – Net Reinsurance Recoveries

Amounts recovered and recoverable from reinsurers on paid losses

Include: Amounts related to assumed and ceded business. Line 18 – Non-Health Claims (net)

Include: Claims for life or property/casualty insurance, net of reinsurance. Line 19 – Claims Adjustment Expenses, Including $___ Cost Containment Expenses

All expenses incurred in connection with the recording, adjustment and settlement of claims. This includes the total of the expense classification “Other Claim Adjustment Expenses” and all “Cost Containment Expenses” in the Underwriting and Investment Exhibit, Part 3, Analysis of Expenses.

Cost Containment Expenses and Other Claim Adjustment Expenses have been defined in SSAP No. 55—Unpaid Claims, Losses and Loss Adjustment Expenses. Refer to SSAP No. 55 for accounting guidance.

Attachment H


Line 20 – General Administrative Expenses

Refer to SSAP No. 70—Allocation of Expenses, for accounting guidance.

Exclude: All expenses related to cost containment activities in accordance with SSAP No. 55—Unpaid Claims, Losses and Loss Adjustment Expenses.

Should equal Analysis of Operations by Lines of Business – Accident and Health, Column 1, Line 21 plus Line 22 plus Line 24.

Line 21 – Increase in Reserves for Accident and Health Contracts

Include: Increase in policy reserves.

Change in premium deficiency reserve. Line 22 – Increase in Reserves for Life Contracts

Include: Increase in policy reserves.

Change in premium deficiency reserve. Detail of Write-ins Aggregated at Line 5 for Other Health Care Related Revenues

Include: Revenue from sources not covered in the other revenue accounts. Detail of Write-ins at Line 6 for Other Non-Health Revenues

Include: Revenue from life and property/casualty business (non-premium amounts).

Gains losses on fixed assets. Details of Write-ins Aggregated at Line 13 for Other Hospital and Medical

Include: Other hospital and medical expenses not covered in the other claims accounts.

Attachment H


ANALYSIS OF OPERATIONS BY LINES OF BUSINESS – ACCIDENT AND HEALTH


Column 1 – Total

Sum of Lines 21 through 24 should equal Health Analysis of Operations by Lines of Business Supplement Line 19 plus 20 (Column 1 minus Column 14).


Line 1 – Premiums for Accident and Health Contracts

Should equal Health Analysis of Operations by Lines of Business Supplement, Line 7 minus Line 6 (Column 1 minus Column 14).


Line 8.3 – Aggregate Write-Ins for Miscellaneous Income

Enter the total of the write-ins listed in schedule Details of Write-ins Aggregated at Line 8.3 for Miscellaneous Income.

Line 13 – Disability Benefits and Benefits Under Accident and Health Contracts

Should equal Health Analysis of Operations by Lines of Business Supplement, Line 17, Column 1 minus Column 14.

Line 16 – Group Conversions

Include: The customary charges, in the appropriate columns, to cover the excess cost arising from group conversions.

This line is not applicable to Fraternal Benefit Societies.

Line 19 – Increase in Aggregate Reserves for Life and Accident and Health Contracts

Should equal the Analysis of Operations by Lines of Business Supplement, Column 1, Line 21 plus Line 22


Attachment H


ANNUAL STATEMENT BLANK –HEALTH

ANALYSIS OF OPERATIONS BY LINES OF BUSINESS

1 Comprehensive (Hospital & Medical)

34 45 56 67 78 89 10 11 12 913 1014

2 3

Total

Comprehensive (Hospital &

Medical) Individual Group

Medicare Supplement Dental Only Vision Only

Federal Employees

Health Benefits Plan

Title XVIII Medicare


Disability Income

Long-Term Care Other Health

Other Non-Health

1. Net premium income ................................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... .......................... 2. Change in unearned premium reserves and reserve

for rate credit ............................................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... ......................... 3. Fee-for-service (net of $......... medical expenses) ....... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 4. Risk revenue ................................................................ ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 5. Aggregate write-ins for other health care related

revenues ....................................................................... ............................ ............................ ......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 6. Aggregate write-ins for other non-health care

related revenues ........................................................... ............................ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX .......................... 7. Total revenues (Lines 1 to 6) ....................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... .......................... 8. Hospital/medical benefits ............................................ ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 9. Other professional services .......................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 10. Outside referrals .......................................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 11. Emergency room and out-of-area ................................ ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 12. Prescription drugs ........................................................ ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 13. Aggregate write-ins for other hospital and medical ..... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 14. Incentive pool, withhold adjustments and bonus

amounts........................................................................ ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 15. Subtotal (Lines 8 to 14) ............................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 16. Net reinsurance recoveries ........................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 17. Total hospital and medical (Lines 15 minus 16) .......... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 18. Non-health claims (net) ............................................... ............................ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX .......................... 19. Claims adjustment expenses including

$………. cost containment expenses ........................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... .......................... 20. General administrative expenses ................................. ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... .......................... 21. Increase in reserves for accident and health

contracts ....................................................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 22. Increase in reserves for life contracts .......................... ............................ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX .......................... 23. Total underwriting deductions (Lines 17 to 22) .......... ............................ ............................ ......................... ....................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... .......................... 24. Net underwriting gain or (loss)

(Line 7 minus Line 23) DETAILS OF WRITE-INS 0501. ..................................................................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 0502. . .................................................................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 0503. ..................................................................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 0598. Summary of remaining write-ins for Line 5 from

overflow page .............................................................. ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 0599. Totals (Lines 0501 through 0503 plus 0598)

(Line 5 above) XXX 0601. ..................................................................................... ............................ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX .......................... 0602. ..................................................................................... ............................ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX .......................... 0603. ..................................................................................... ............................ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX .......................... 0698. Summary of remaining write-ins for Line 6 from

overflow page .............................................................. ............................ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX .......................... 0699. Totals (Lines 0601 through 0603 plus 0698)

(Line 6 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1301. ..................................................................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 1302. ..................................................................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 1303. ..................................................................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 1398. Summary of remaining write-ins for Line 13 from


(Line 13 above) XXX

Attachment H


ANNUAL STATEMENT BLANK – LIFE\FRATERNAL

HEALTH ANALYSIS OF OPERATIONS BY LINES OF BUSINESS SUPPLEMENT


4 5 6 7 8 9 10 11 12 13 14

2 3 Federal

Total Individual Group Medicare

Supplement Dental Only Vision Only

Employees Health

Benefits Plan Title XVIII Medicare


Disability Income


Other Non-Health

1. Net premium income ................................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... .......................... 2. Change in unearned premium reserves and reserve

for rate credit ............................................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... ......................... 3. Fee-for-service (net of $......... medical expenses) ....... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 4. Risk revenue ................................................................ ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 5. Aggregate write-ins for other health care related

revenues ....................................................................... ............................ ............................ ......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 6. Aggregate write-ins for other non-health care

related revenues ........................................................... ............................ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX .......................... 7. Total revenues (Lines 1 to 6) ....................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... .......................... 8. Hospital/medical benefits ............................................ ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 9. Other professional services .......................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 10. Outside referrals .......................................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 11. Emergency room and out-of-area ................................ ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 12. Prescription drugs ........................................................ ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 13. Aggregate write-ins for other hospital and medical ..... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 14. Incentive pool, withhold adjustments and bonus

amounts........................................................................ ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 15. Subtotal (Lines 8 to 14) ............................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 16. Net reinsurance recoveries ........................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 17. Total hospital and medical (Lines 15 minus 16) .......... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 18. Non-health claims (net) ............................................... ............................ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX .......................... 19. Claims adjustment expenses including

$………. cost containment expenses ........................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... .......................... 20. General administrative expenses ................................. ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... .......................... 21. Increase in reserves for accident and health

contracts ....................................................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 22. Increase in reserves for life contracts .......................... ............................ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX .......................... 23. Total underwriting deductions (Lines 17 to 22) .......... ............................ ............................ ......................... ....................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... .......................... 24. Net underwriting gain or (loss)

(Line 7 minus Line 23) DETAILS OF WRITE-INS 0501. ..................................................................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 0502. . .................................................................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 0503. ..................................................................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 0598. Summary of remaining write-ins for Line 5 from


(Line 5 above) XXX 0601. ..................................................................................... ............................ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX .......................... 0602. ..................................................................................... ............................ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX .......................... 0603. ..................................................................................... ............................ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX .......................... 0698. Summary of remaining write-ins for Line 6 from

overflow page .............................................................. ............................ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX .......................... 0699. Totals (Lines 0601 through 0603 plus 0698)

(Line 6 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1301. ..................................................................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 1302. ..................................................................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 1303. ..................................................................................... ............................ ............................ ......................... .......................... .......................... .......................... ....................... ........................... .......................... ........................ ........................ ........................ ....................... XXX 1398. Summary of remaining write-ins for Line 13 from


(Line 13 above) XXX


Attachment I




DATE: 10/19/2021

CONTACT PERSON:

TELEPHONE:


NAME: Jamie Walker

TITLE: Deputy Commissioner

AFFILIATION: Texas Department of Insurance

ADDRESS:







[ X ] Life, Accident & Health/Fraternal [ ] Separate Accounts [ ] Title [ ] Property/Casualty [ ] Protected Cell [ ] Other _______________________ [ ] Health [ X ] Health (Life Supplement)


IDENTIFICATION OF ITEM(S) TO CHANGE Modify the Life Insurance (State Page) to include the line of business detail reported on the Analysis of Operations by Lines of Business pages. Two new Schedule T style pages (Exhibit of Claims Settled During the Current Year and Policy Exhibit) are created to include detail captured by state on the existing Life Insurance (State Page) that could not be included due space issue. Adds definitions for life and annuity products to the lines of business definitions in the health appendix

REASON, JUSTIFICATION FOR AND/OR BENEFIT OF CHANGE** The purpose of this proposal is to make the lines of business reported on the Life Insurance (Sate Page) consistent with the lines of business being reported on the Analysis of Operations by Lines of Business pages.


Attachment I



STATE PAGE A schedule should be prepared and submitted to the state of domicile for each jurisdiction in which the company has written direct business, has direct losses paid or direct losses incurred. To other states in which the company is licensed it should submit only a schedule for that state. Direct premiums by state may be estimated by formula on the basis of countrywide ratios for the respective lines of business except where adjustments are required to recognize special situations. Company’s participation in the FEGLI and SGLI policies is shown in this exhibit as direct business. This exhibit should be shown excluding reinsurance assumed. Reinsurance ceded should not be deducted. Fraternal entities should leave blank any data elements not applicable such as group and credit. For definitions of lines of business, see the appendix of these instructions. Column 2 – Credit Life (Group and Individual)

Include: Business not exceeding 120 months duration.

This column is not applicable to Fraternal Benefit Societies. Column 5 – Total

Line 1 – Direct Premiums for Life Contracts Excluding Reinsurance Assumed and Without Deduction of Reinsurance Ceded and

Line 2 – Direct Annuity Considerations for Life Contracts Excluding Reinsurance Assumed and Without Deduction of Reinsurance Ceded

Should equal Schedule T, Columns 2 and 3, by State.

Line 3 – Deposit-type Contract Funds

Report all deposits, and other amounts received for contracts without any mortality and morbidity risk and not reported on Line 1, Line 2 or Line 4. The amounts reported should be consistent with those reported on Schedule T, Column 7.

Line 2 – Annuity Considerations

Should equal Schedule T, Column 3 by State. Line 3 – Deposit-type Contracts Funds

Report all deposits and other amounts received for contracts without any mortality and morbidity risk and not reported on Line 1, Line 2 or Line 4. The amounts reported should be consistent with those reported on Schedule T, Column 7.

}

Attachment I


Line 4 – Other Considerations

Include: Unallocated annuity considerations and other unallocated deposits that incorporate any mortality or morbidity risk and are not reported on Line 1, Line 2 or Line 3. The amounts reported should be consistent with those reported on Schedule T, Column 5. See the instructions to the Life, Health & Annuity Guaranty Association Model Act Assessment Base Reconciliation Exhibit and Adjustments to the Life, Health & Annuity Guaranty Association Model Act Assessment Base Reconciliation Exhibit for allocated and unallocated annuities. Report allocated annuities in Line 2.

Line 6 – Life Insurance Direct Dividends to Policyholders/Refunds to Members Excluding

Reinsurance Assumed and Without Deduction of Reinsurance Ceded and Line 7 – Annuity Direct Dividends to Policyholders/Refunds to Members Excluding

Reinsurance Assumed and Without Deduction of Reinsurance Ceded

Report dividends to policyholders/refunds to members paid or left on deposit, dividends applied to policyholders/refunds to members to pay premiums or considerations or applied to provide paid-up additions or annuities. Also report dividends to policyholders/refunds to members used to shorten the endowment or premium paying period.

Line 13 – Aggregate Write-ins for Miscellaneous Direct Claims and Benefits Paid

Enter the total of the write-ins listed in schedule Detail of Write-ins Aggregated at Line 13 for Miscellaneous Direct Claims and Benefits Paid.

Lines 24 to 26 – Accident and Health Insurance

Report health premiums collected during the year, excluding reinsurance accepted and without deduction of reinsurance ceded.

Report on Line 24.1 those premiums, dividends and losses allocable to the Federal Employees Health Benefits Program premiums that are exempted from state taxes or other fees by Section 8909(f)(1) of Title 5 of the United States Code.

For Line 24.2, include business not exceeding 120 months’ duration.

For Line 25, the development of data into various health policy categories should be done by inventory of the policy records.

Line 24.4 – Medicare Title XVIII Exempt from State Taxes or Fees

Report Medicare Title XVIII premiums that are exempted from state taxes or other fees by Section 1854(g) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. This includes but is not limited to premiums written under a Medicare Advantage product, a Medicare PPO product, or a stand-alone Medicare part D product.

Details of Write-ins Aggregated on Line 13 for Miscellaneous Direct Claims and Benefits Paid

List separately each category of direct claims and benefits paid for which there is no pre-printed line on the state page.

}

Attachment I


Column 1 – Premiums and Annuities Considerations

Line 12 plus Line 20 should equal Schedule T, Columns 2, by State. Line 27 plus Line 34 should equal Schedule T, Columns 3, by State. Line 47 should equal Schedule T, Columns 4, by State.

Line 48 (Column1 plus Column 2) should equal Schedule T, Columns 6, by State.

Column 2 – Other Considerations

Include: Unallocated annuity considerations and other unallocated deposits that incorporate any mortality or morbidity risk and are not reported on Column 1, The amounts reported should be consistent with those reported on Schedule T, Column 5. See the instructions to the Life, Health & Annuity Guaranty Association Model Act Assessment Base Reconciliation Exhibit and Adjustments to the Life, Health & Annuity Guaranty Association Model Act Assessment Base Reconciliation Exhibit for allocated and unallocated annuities. Report allocated annuities on Column 1.

Line 48 should equal Schedule T, Columns 5, by State.

Dividends to Policyholders/Refunds to Members Column 3 – Paid in Cash or Left on Deposit Column 4 – Applied to Pay Renewal Premiums Column 5 – Applied to Provide Paid-Up Additions or Shorten the Endowment or Premium-Paying Period and Column 6 – Other


Claims and Benefits Paid Column 8 – Death and Annuity Benefits Column 9 – Matured Endowments and Column 10 – Surrender Values and Withdrawals for Life Contracts

These columns are only applicable to life and annuity contracts (Lines 1 through 34) Column 11 – All Other Benefits

Report claims benefits paid for accident and health contracts (Lines 35 through 47) in this column. Death Benefits and Matured Endowments Incurred Column 13 – Incurred During Current Year

These columns are only applicable to life and annuity contracts (Lines 1 through 34)

}

}

Attachment I


Column 14 – Total Claims Settlements


Should equal Column 12 of the Exhibit of Claims Settled During Current Year by state. Column 15 – Unpaid December. 31, Current Year


Should equal Column 15 (prior year) plus Column 13 minus Column 14. Footnote c:

Total considerations amount should equal Schedule T, Columns 7, by State. For Health Business:

Complete the information in Footnote d below the Accident and Health block regarding number of persons covered under PPO managed care products and number of persons covered under indemnity only products. Include in PPO business health insurance products that provide access to a higher level of benefits whenever participating provider networks are used.

Attachment I


POLICY EXHIBIT Allocated by States and Territories

This exhibit should be shown excluding reinsurance assumed. Reinsurance ceded should not be deducted. In Force December 31, Current Year

Sum of Columns 5, 11 and 17 should equal Column 16 of Life Insurance (State Page) by state.

Sum of Columns 6, 12 and 18 should equal Column 17 of Life Insurance (State Page) by state. Column 5 – In Force December 31, Current Year – Number of Pols\Certs – Life Contracts

Should equal Column 5 (prior year) plus Column 1 plus Column 3 Column 6 – In Force December 31, Current Year – Amount – Life Contracts

Should equal Column 6 (prior year) plus Column 2 plus Column 4 Column 11 – In Force December 31, Current Year – Number of Pols\Certs – Annuities Contracts

Should equal Column 11 (prior year) plus Column 7 plus Column 9 Column 12 – In Force December 31, Current Year – Amount – Annuities Contracts

Should equal Column 12 (prior year) plus Column 8 plus Column 10 Column 17 – In Force December 31, Current Year – Number of Pols\Certs – Accident and Health Contracts

Should equal Column 17 (prior year) plus Column 13 plus Column 15 Column 18 – In Force December 31, Current Year – Amount – Accident and Health Contracts

Should equal Column 18 (prior year) plus Column 14 plus Column 16

Attachment I


EXHIBIT OF CLAIMS SETTLED DURING CURRENT YEAR Allocated by States and Territories

This exhibit should be shown excluding reinsurance assumed. Reinsurance ceded should not be deducted. Column 1 – By Payment in Full – Pols\Certs Column 2 – By Payment in Full – Amount

Provide the amount for claims settled by full payment and the number of policies\certificates for the claims settled by full payment.

Column 3 – By payment on Compromised Claims – Pols\Certs Column 4 – By payment on Compromised Claims – Amount

Provide the amount for claims settled by payment on Compromised Claims and the number of policies\certificates for the claims settled by payment on Compromised Claims.

Column 7 – Reduction by Compromise – Pols\Certs Column 8 – Reduction by Compromise – Amount

Provide the amount for claims reduced by compromise and the number of policies\certificates for the claims reduced by compromise.

Column 9 – Amount Rejected – Pols\Certs Column 10 – Amount Rejected – Amount

Provide the amount for claims rejected and the number of policies\certificates for the claims rejected. Total Settled During Current Year Column 11 – Pols\Certs

Provide the total number of policies\certificates for claims settled during the current year. Column 12 – Amount (Col 6+8+10)

Should equal Column 14 of Life Insurance (State Page) by state.

}

} }

}

}

Attachment I


ANNUAL STATEMENT INSTRUCTIONS – HEALTH (LIFE SUPPLEMENT)

LIFE SUPPLEMENT TO THE HEALTH ANNUAL STATEMENT

NOTE: Only companies licensed as Life, Accident & Health insurers should complete the schedules included in the

Life Supplement to the Health Annual Statement.


STATE PAGE To be filed on or before March 1. Only companies licensed as Life, Accident & Health insurers should complete this schedule. A schedule should be prepared and submitted to the state of domicile for each jurisdiction in which the company has written direct business, has direct losses paid or direct losses incurred. To other states in which the company is licensed it should submit only a schedule for that state. Direct premiums by state may be estimated by formula on the basis of countrywide ratios for the respective lines of business except where adjustments are required to recognize special situations. Company’s participation in the FEGLI and SGLI policies is shown in this exhibit as direct business. This exhibit should be shown excluding reinsurance assumed. Reinsurance ceded should not be deducted. For definitions of lines of business, see the appendix of these instructions. Column 2 – Credit Life (Group and Individual)

Include: Business not exceeding 120 months duration. Column 5 – Total

Line 1 – Direct Premiums for Life Contracts Excluding Reinsurance Assumed and Without Deduction of Reinsurance Ceded and

Line 2 – Direct Annuity Considerations for Life Contracts Excluding Reinsurance Assumed and Without Deduction of Reinsurance Ceded

The amounts reported should be consistent with those reported on Schedule T, Column 6.

Line 3 – Deposit-type Contracts Fund

Report all deposits and other amounts received for contracts without any mortality and morbidity risk and not reported on Line 1, Line 2 or Line 4. The amounts reported should be consistent with those reported on Schedule T, Column 9.

}

Attachment I


Line 4 – Other Considerations

Include: Unallocated annuity considerations and other unallocated deposits which incorporate any mortality or morbidity risk and are not reported on Line 1, Line 2 or Line 3. See the instructions to the Life, Health & Annuity Guaranty Association Model Act Assessment Base Reconciliation Exhibit and Adjustments to the Life, Health & Annuity Guaranty Association Model Act Assessment Base Reconciliation Exhibit for allocated and unallocated annuities. Report allocated annuities in Line 2.

Line 6 – Life Insurance Direct Dividends to Policyholders Excluding Reinsurance Assumed and

Without Deduction of Reinsurance Ceded and Line 7 – Annuity Direct Dividends to Policyholders Excluding Reinsurance Assumed and

Without Deduction of Reinsurance Ceded Report dividends paid or left on deposit, dividends applied to pay premiums or considerations, or applied to

provide paid-up additions or annuities. Also report dividends used to shorten the endowment or premium paying period.

Line 13 – Aggregate Write-ins for Miscellaneous Direct Claims and Benefits Paid

Enter the total of the write-ins listed in schedule Detail of Write-ins Aggregated at Line 13 for Miscellaneous Direct Claims and Benefits Paid.

Lines 24 to 26 – Accident and Health Insurance

Report health premiums collected during the year, excluding reinsurance accepted and without deduction of reinsurance ceded.

Report on Line 24.1 those premiums, dividends and losses allocable to the Federal Employees Health Benefits Plan premiums that are exempted from state taxes or other fees by Section 8909(f)(1) of Title 5 of the United States Code.

For Line 24.2, include business not exceeding 120 months’ duration.

For Line 25, the development of data into various health policy categories should be done by inventory of the policy records.

Details of Write-ins Aggregated on Line 13 for Miscellaneous Direct Claims and Benefits Paid

List separately each category of direct claims and benefits paid for which there is no pre-printed line on the state page.

}

Attachment I


Column 1 – Premiums and Annuities Considerations

Line 12 plus Line 20 should equal Schedule T, Columns 2, by State. Line 27 plus Line 34 should equal Schedule T, Columns 3, by State. Line 47 should equal Schedule T, Columns 4, by State.

Line 48 (Column1 plus Column 2) should equal Schedule T, Columns 6, by State.

Column 2 – Other Considerations

Include: Unallocated annuity considerations and other unallocated deposits that incorporate any mortality or morbidity risk and are not reported on Column 1,. The amounts reported should be consistent with those reported on Schedule T, Column 5. See the instructions to the Life, Health & Annuity Guaranty Association Model Act Assessment Base Reconciliation Exhibit and Adjustments to the Life, Health & Annuity Guaranty Association Model Act Assessment Base Reconciliation Exhibit for allocated and unallocated annuities. Report allocated annuities on Column 1.

Line 48 should equal Schedule T, Columns 5, by State.

Dividends to Policyholders/Refunds to Members Column 3 – Paid in Cash or Left on Deposit Column 4 – Applied to Pay Renewal Premiums Column 5 – Applied to Provide Paid-Up Additions or Shorten the Endowment or Premium-Paying Period and Column 6 – Other


Claims and Benefits Paid Column 8 – Death and Annuity Benefits Column 9 – Matured Endowments and Column 10 – Surrender Values and Withdrawals for Life Contracts

These columns are only applicable to life and annuity contracts (Lines 1 through 34) Column 11 – All Other Benefits

Report claims benefits paid for accident and health contracts (Lines 35 through 47) in this column. Death Benefits and Matured Endowments Incurred Column 13 – Incurred During Current Year


}

}

Attachment I


Column 14 – Total Claims Settlements


Should equal Column 12 of the Exhibit of Claims Settled During Current Year by state Column 15 – Unpaid December. 31, Current Year


Should equal Column 15 (prior year) plus Column 13 minus Column 14. Footnote c:

Total considerations amount should equal Schedule T, Columns 7, by State. For Health Business:

Complete the information in Footnote d below the Accident and Health block regarding number of persons covered under PPO managed care products and number of persons covered under indemnity only products. Include in PPO business health insurance products that provide access to a higher level of benefits whenever participating provider networks are used.

Attachment I



This exhibit should be shown excluding reinsurance assumed. Reinsurance ceded should not be deducted. In Force December 31, Current Year

Sum of Columns 5, 11 and 17 should equal Column 16 of Life Insurance (State Page) by state.

Sum of Columns 6, 12 and 18 should equal Column 17 of Life Insurance (State Page) by state. Column 5 – In Force December 31, Current Year – Number of Pols\Certs – Life Contracts

Should equal Column 5 (prior year) plus Column 1 plus Column 3 Column 6 – In Force December 31, Current Year – Amount – Life Contracts

Should equal Column 6 (prior year) plus Column 2 plus Column 4 Column 11 – In Force December 31, Current Year – Number of Pols\Certs – Annuities Contracts

Should equal Column 11 (prior year) plus Column 7 plus Column 9 Column 12 – In Force December 31, Current Year – Amount – Annuities Contracts

Should equal Column 12 (prior year) plus Column 8 plus Column 10 Column 17 – In Force December 31, Current Year – Number of Pols\Certs – Accident and Health Contracts

Should equal Column 17 (prior year) plus Column 13 plus Column 15 Column 18 – In Force December 31, Current Year – Amount – Accident and Health Contracts

Should equal Column 18 (prior year) plus Column 14 plus Column 16

Attachment I



This exhibit should be shown excluding reinsurance assumed. Reinsurance ceded should not be deducted. Column 1 – By Payment in Full – Pols\Certs Column 2 – By Payment in Full – Amount

Provide the amount for claims settled by full payment and the number of policies\certificates for the claims settled by full payment.

Column 3 – By payment on Compromised Claims – Pols\Certs Column 4 – By payment on Compromised Claims – Amount

Provide the amount for claims settled by payment on Compromised Claims and the number of policies\certificates for the claims settled by payment on Compromised Claims.

Column 7 – Reduction by Compromise – Pols\Certs Column 8 – Reduction by Compromise – Amount

Provide the amount for claims reduced by compromise and the number of policies\certificates for the claims reduced by compromise.

Column 9 – Amount Rejected – Pols\Certs Column 10 – Amount Rejected – Amount

Provide the amount for claims rejected and the number of policies\certificates for the claims rejected. Total Settled During Current Year Column 11 – Pols\Certs

Provide the total number of policies\certificates for claims settled during the current year. Column 12 – Amount (Col 6+8+10)

Should equal Column 14 of Life Insurance (State Page) by state.

}

} }

}

}

Attachment I



DEFINITIONS OF LINES OF BUSINESS – ACCIDENT AND HEALTH Riders/Endorsements/Floaters:



Other (Specify):

Coverage provided by entities that do not fall within any of the other categories, including stop loss, disability and long-term care. Indemnity plans where the insured person is reimbursed for covered expenses would fall within this area.

DEFINITIONS OF LINES OF BUSINESS – LIFE Credit life insurance:

Insurance on a debtor or debtors, pursuant to or in connection with a specific loan or other credit transaction, to provide for satisfaction of a debt, in whole or in part, upon the death of an insured debtor.

Indexed life insurance:

Any universal life insurance policy where the interest credits are linked to an external referent. Industrial life insurance:

Insurance under which premiums are paid monthly or more often, the face amount of the policy does not exceed a stated amount, and the words “industrial policy” are printed in prominent type on the face of the policy. Also called “debit” insurance.

Interest-sensitive whole life contract:

If the gross premiums are fixed and required to be paid, it would be treated like whole life; if gross premiums are flexible and not required to be paid, it would be treated like universal life.

Attachment I


Group life contract:

Insurance on the lives of a group of persons under a single master contract. Life insurance:

The primary purpose is to provide financial assistance to a beneficiary at the insured’s death. Net cash surrender value:

The maximum amount payable to the policyowner upon surrender. Ordinary life insurance:

Contract between the company and the policy owner (often the insured). Many variations of ordinary life coverages are available to a purchaser of insurance, including participating, limited-payment periods, combinations of coverages, and decreasing (or increasing) death benefits.

Policy value:

The amount to which separately identified interest credits and mortality, expense or other charges are made under a universal life insurance policy.

Preneed:

“Preneed funeral contract or prearrangement” means an agreement by or for an individual before that individual’s death relating to the purchase or provision of specific funeral or cemetery merchandise or services. For reporting purposes, also included in this category are final expense plans that may cover medical bills in addition to funeral expenses.

Secondary Guarantee:

A “secondary guarantee” means a conditional guarantee that a policy will remain in force for either:

a. More than five years (the secondary guarantee period).

b. Five years or less (the secondary guarantee period) if the specified premium for the secondary guarantee period is less than the net level reserve premium for the secondary guarantee period based on the CSO valuation tables defined in VM-20 Section 3.C and VM-M and the valuation interest rates defined in this Section, or if the initial surrender charge is less than 100% of the first year annualized specified premium for the secondary guaranteed period, even if its fund value is exhausted.

Term life contract:

Provides insurance over a specified period of time. If the insured dies during this term, the face amount of the policy will be paid to the beneficiary.

Attachment I


Universal life contract:

Includes those contracts that have terms that are not fixed and guaranteed relative to premium amounts, expense assessments or benefits accruing to the policyholder. These contracts generally provide for death benefits and nonforfeiture values and may be issued on a fixed premium basis or on a flexible premium basis where the premiums are paid at the insured’s discretion.

Fixed premium universal life insurance policy:

A universal life insurance policy other than a flexible premium universal life insurance policy.

Flexible premium universal life insurance policy:

A universal life insurance policy that permits the policyowner to vary, independently of each other, the amount or timing of one or more premium payments or the amount of insurance.

Variable Universal Life:

Life insurance that provides a face amount that is adjustable to the certificate/policy holder and may allow the certificate/policy holder to vary the modal premium that is paid or may skip a payment so long as the certificate/policy value is sufficient to keep the certificate/policy in force, and under which separately identified interest credits (other than in connection with dividend accumulation, premium deposit funds or other supplementary accounts) and mortality and expense charges are made to individual certificates or policies while providing minimum guaranteed values.

Universal life insurance policy:

A life insurance policy where separately identified interest credits (other than in connection with dividend accumulations, premium deposit funds or other supplementary accounts) and mortality and expense charges are made to the policy. A universal life insurance policy may provide for other credits and charges, such as charges for the cost of benefits provided by rider.

Variable life contract:

A policy that provides for life insurance, the amount or duration of which varies according to the investment experience of any separate account or accounts established and maintained by the insurer as to the policy.

Whole life contract:

Provides a fixed amount of insurance coverage over the life of the insured and the related benefits are normally payable only upon the insured’s death.

Attachment I


DEFINITIONS OF LINES OF BUSINESS – ANNUITIES Annuity contract:

An arrangement whereby an annuitant is guaranteed to receive a series of stipulated amounts commencing either immediately or at some future date.

Contingent Deferred Annuity (CDA):

An annuity contract that establishes a life insurer's obligation to make periodic payments for the annuitant's lifetime at the time designated investments, which are not owned or held by the insurer, are depleted to a contractually defined amount due to contractually permitted withdrawals, market performance, fees and/or other charges. A CDA is an insurance product that provides protection against underperforming and downward performing markets in the form of an income guarantee on outside investment accounts owned by an insured. The income guarantee is provided through the collection of ongoing fees from within these outside investment accounts. The insured must agree to certain portfolio restrictions and must first deplete their outside investment account assets at the CDA guaranteed income amount and rate according to the contract and prior to the insurer's assumption of this amount. A CDA is considered a living benefit added to an investment account.

Fixed annuity:

A fixed annuity is a policy or contract that has a specified crediting rate periodically and unilaterally adjusted by the company not below minimum contract rate.

Guaranteed Interest Contracts (GICs):

Contracts that guarantee principal and interest for a specified period of time and include the option to purchase immediate annuities that depend on the survival of the annuitant.

Interest-indexed annuity contract:

Any annuity contract where the interest credits are linked to an external reference. Supplementary contracts with life contingencies:

A type of agreement between the insurance company and either the insured or the beneficiary, usually to provide for full or partial settlement of the amount payable upon the termination of an original contract.

Variable annuity:

A policy or contract, individual or group, that provides for annuity benefits that vary according to the investment experience of a separate account or accounts maintained by the insurer as to the policy or contract.

Attachment I


ANNUAL STATEMENT BLANK – LIFE\FRATERNAL DIRECT BUSINESS IN THE STATE OF DURING THE YEAR .

NAIC Group Code........................ LIFE INSURANCE NAIC Company Code................................

DIRECT PREMIUMS AND ANNUITY CONSIDERATIONS

1

Ordinary

2 Credit Life

(Group and Individual)

3

Group

4

Industrial

5

Total 1. Life insurance ...............................................................................................2. Annuity considerations .................................................................................3. Deposit-type contract funds ..........................................................................4. Other considerations .....................................................................................5. Totals (Sum of Lines 1 to 4)

................................................ ................................................ ................................................ ................................................

................................................ ................................................

XXX ................................................

............................................... ............................................... ............................................... ...............................................

................................................ ................................................

XXX ................................................

................................................ ................................................ ................................................ ................................................

DIRECT DIVIDENDS TO POLICYHOLDERS/REFUNDS TO MEMBERS

Life insurance: 6.1 Paid in cash or left on deposit ......................................................................6.2 Applied to pay renewal premiums ................................................................6.3 Applied to provide paid-up additions or shorten the endowment or

premium-paying period ................................................................................6.4 Other .............................................................................................................6.5 Totals (Sum of Lines 6.1 to 6.4) ...................................................................Annuities: 7.1 Paid in cash or left on deposit ......................................................................7.2 Applied to provide paid-up annuities ...........................................................7.3 Other .............................................................................................................7.4 Totals (Sum of Lines 7.1 to 7.3) ...................................................................8. Grand Totals (Lines 6.5 + 7.4)

................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................

................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................

............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ...............................................

................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................

................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................

DIRECT CLAIMS AND BENEFITS PAID 9. Death benefits ...............................................................................................10. Matured endowments ...................................................................................11. Annuity benefits ...........................................................................................12. Surrender values and withdrawals for life contracts .....................................13. Aggregate write-ins for miscellaneous direct claims and benefits paid .......14. All other benefits, except accident and health ..............................................15. Totals

................................................ ................................................ ................................................ ................................................ ................................................ ................................................

................................................ ................................................ ................................................ ................................................ ................................................ ................................................

............................................... ............................................... ............................................... ............................................... ............................................... ...............................................

................................................ ................................................ ................................................ ................................................ ................................................ ................................................

................................................ ................................................ ................................................ ................................................ ................................................ ................................................

DETAILS OF WRITE-INS 1301. ......................................................................................................................1302. ......................................................................................................................1303. ......................................................................................................................1398. Summary of remaining write-ins for Line 13 from overflow page ..............1399. Total (Lines 1301 through 1303 + 1398) (Line 13 above)

................................................ ................................................ ................................................ ................................................

................................................ ................................................ ................................................ ................................................

............................................... ............................................... ............................................... ...............................................

................................................ ................................................ ................................................ ................................................

................................................ ................................................ ................................................ ................................................

Ordinary

Credit Life (Group and Individual)

Group

Industrial

Total

DIRECT DEATH BENEFITS AND MATURED ENDOWMENTS INCURRED

1

No. of Pols. & Certifs.

2

Amount

3 No. of Ind. Pols. & Gr.

Certifs.

4

Amount

5

No. of Certifs.

6

Amount

7


8

Amount

9


10

Amount

16. Unpaid December 31, prior year ..................................................................17. Incurred during current year .........................................................................

Settled during current year: 18.1 By payment in full ........................................................................................18.2 By payment on compromised claims ...........................................................18.3 Totals paid ....................................................................................................18.4 Reduction by compromise ............................................................................18.5 Amount rejected ...........................................................................................18.6 Total settlements ..........................................................................................19. Unpaid Dec. 31, current year (Lines 16 + 17 - 18.6)

.................... .................... .................... .................... .................... .................... .................... ....................

.................... .................... .................... .................... .................... .................... .................... ....................

.................... .................... .................... .................... .................... .................... .................... ....................

.................... .................... .................... .................... .................... .................... .................... ....................

................... ................... ................... ................... ................... ................... ................... ...................

.................... .................... .................... .................... .................... .................... .................... ....................

.................... .................... .................... .................... .................... .................... .................... ....................

................... ................... ................... ................... ................... ................... ................... ...................

.................... .................... .................... .................... .................... .................... .................... ....................

.................... .................... .................... .................... .................... .................... .................... ....................

POLICY EXHIBIT

No. of Policies

20. In force December 31, prior year .................................................................21. Issued during year ........................................................................................22. Other changes to in force (Net) ....................................................................23. In force December 31 of current year

.................... .................... ....................

.................... .................... ....................

.................... .................... ....................

(a) ................ .................... .................... (a)

................... ................... ...................

.................... .................... ....................

.................... .................... ....................

................... ................... ...................

.................... .................... ....................

.................... .................... ....................

(a) Includes Individual Credit Life Insurance prior year $...................................................................., current year $....................................................................... Includes Group Credit Life Insurance Loans less than or equal to 60 months at issue, prior year $...................................................................., current year $................................................................... Loans greater than 60 months at issue BUT NOT GREATER THAN 120 MONTHS prior year $................................................................., current year $................................................................

ACCIDENT AND HEALTH INSURANCE

1

Direct Premiums

2 Direct

Premiums Earned

3 Policyholder Dividends

Paid, Refunds to Members or Credited on

Direct Business

4 Direct Losses Paid

5 Direct Losses

Incurred

24. Group policies (b) ...........................................................................................24.1 Federal Employees Health Benefits Plan premium (b) ..................................24.2 Credit (Group and Individual) ........................................................................24.3 Collectively renewable policies/certificates (b)..............................................24.4 Medicare Title XVIII exempt from state taxes or fees ................................... Other Individual Policies: 25.1 Non-cancelable (b) .........................................................................................25.2 Guaranteed renewable (b) .............................................................................25.3 Non-renewable for stated reasons only (b) .....................................................25.4 Other accident only ........................................................................................25.5 All other (b) ....................................................................................................25.6 Totals (sum of Lines 25.1 to 25.5) .................................................................26. Totals (Lines 24 + 24.1 + 24.2 + 24.3 + 24.4 + 25.6)

............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ...............................................

................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................

............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ...............................................

............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ...............................................

............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ...............................................

(b) For health business on indicated lines report: Number of persons insured under PPO managed care products ________________ and number of persons insured under indemnity only products ____________ .

Attachment I


DIRECT BUSINESS IN THE STATE OF DURING THE YEAR

NAIC Group Code…….................. LIFE INSURANCE NAIC Company Code….............................

1 2 Dividends to Policyholders/Refunds to Members Claims and Benefits Paid Death Benefits and Matured

Endowments Incurred Policy Exhibit

3 4 5 6 7 8 9 10 11 12 13 14 15 In Force December 31,

Current Year (b)

Line of Business

Premiums and Annuities

Considerations Other

Considerations Paid in Cash or Left on Deposit

Applied to Pay Renewal

Premiums

Applied to Provide Paid-Up

Additions or Shorten the Endowment

or Premium- Paying Period Other

Total (Col.

3+4+5+6)

Death and Annity

Benefits Matured

Endowments

Surrender Values and

Withdrawals for Life

Contracts All Other Benefits

Total (Sum Columns 8 through 11)

Incurred During Current

Year Total Claims Settlements

Unpaid December. 31, Current Year

16 Number of Policies/

Certificates

17

Amount Individual Life 1. Industrial ....................................... ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ...................... ...................... ....................... ...................... 2. Whole ........................................... ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 3. Term ............................................. ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 4. Indexed ......................................... ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 5. Universal ....................................... ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 6. Universal with Secondary

Guarantees .................................... ........................

.......................

..........................

.........................

..................................

..........................

..........................

.........................

.........................

..........................

..........................

..........................

.........................

.........................

..........................

...........................

...........................

8. Variable ........................................ ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 9. Variable Universal ........................ ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 10. Credit ........................................... ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ...................... (a) 11. Other ............................................ ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 12. Total Individual Life Group Life 13. Whole ........................................... ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 14. Term ............................................. ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 15. Universal ....................................... ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 16. Variable ........................................ ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 17. Variable Universal ........................ ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 18. Credit ............................................ ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ...................... (a) 19. Other ............................................. ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 20. Total Group Life Individual Annuities 21. Fixed ............................................. ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 22. Indexed ......................................... ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 23. Variable with Guarantees ............. ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 24. Variable without Guarantees ........ ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 25. Life Contingent Payout ................. ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 26. Other ............................................. ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 27. Total Individual Annuities Group Annuities 28. Fixed ............................................. ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 29. Indexed ......................................... ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 30. Variable with Guarantees ............. ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 31. Variable without Guarantees ........ ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 32. Contingent Payout ........................ ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 33. Other ............................................. ........................ ....................... .......................... ......................... .................................. .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... .......................... ........................... ........................... 34. Total Group Annuities Accident and Health 35. Comprehensive Individual ............ ........................ ....................... .......................... ......................... .................................. .......................... .......................... XXX XXX XXX .......................... .......................... XXX XXX XXX ........................... ........................... 36. Comprehensive Group .................. ........................ ....................... .......................... ......................... .................................. .......................... .......................... XXX XXX XXX .......................... .......................... XXX XXX XXX ........................... ........................... 37. Medicare Supplement ................... ........................ ....................... .......................... ......................... .................................. .......................... .......................... XXX XXX XXX .......................... .......................... XXX XXX XXX ........................... ........................... 38. Dental Only .................................. ........................ ....................... .......................... ......................... .................................. .......................... .......................... XXX XXX XXX .......................... .......................... XXX XXX XXX ........................... ........................... 39. Vision Only .................................. ........................ ....................... .......................... ......................... .................................. .......................... .......................... XXX XXX XXX .......................... .......................... XXX XXX XXX ........................... ........................... 40. Federal Employees Health

Benefits Plan ................................. ........................

.......................

..........................

.........................

..................................

..........................

..........................

XXX

XXX

XXX

..........................

..........................

XXX

XXX

XXX

...........................

...........................

41. Title XVIII Medicare (d) .............. ................... (e) ....................... .......................... ......................... .................................. .......................... .......................... XXX XXX XXX .......................... .......................... XXX XXX XXX ........................... ........................... 42. Title XIX Medicaid ...................... ........................ ....................... .......................... ......................... .................................. .......................... .......................... XXX XXX XXX .......................... .......................... XXX XXX XXX ........................... ........................... 43. Credit A&H .................................. ........................ ....................... .......................... ......................... .................................. .......................... .......................... XXX XXX XXX .......................... .......................... XXX XXX XXX ........................... ........................... 44. Disability Income ......................... ........................ ....................... .......................... ......................... .................................. .......................... .......................... XXX XXX XXX .......................... .......................... XXX XXX XXX ........................... ........................... 45. Long-Term Care ........................... ........................ ....................... .......................... ......................... .................................. .......................... .......................... XXX XXX XXX .......................... .......................... XXX XXX XXX ........................... ........................... 46. Other Health ................................. ........................ ....................... .......................... ......................... .................................. .......................... .......................... XXX XXX XXX .......................... .......................... XXX XXX XXX ........................... ........................... 47. Total Accident and Health XXX XXX XXX XXX XXX XXX 48. TOTAL (c)

(a) Includes Group Credit Life Insurance Loans less than or equal to 60 months at issue, prior year $........................., current year $.......................... Loans greater than 60 months at issue BUT NOT GREATER THAN 120 MONTHS prior year $........................., current year $.........................

(b) ..Corporate Owned Life Insurance/BOLI: 1) Number of policies: .........................2) covering number of lives: .........................3) face amount: .........................

(c) ..Deposit-Type Contract Considerations NOT included in Total Premiums and Annuities Considerations: Individual: $......................... Group: $......................... Total: $.........................

(d) For health business: number of persons insured under PPO managed care products ......................... and number of persons insured under indemnity only products.........................

(e) For health premiums written: amount of Medicare Title XVIII exempt from state taxes or fees $.........................

Attachment I



Life Contracts Annuity Contracts Accident and Health Contracts

Issued During Year Other Changes to

In Force (Net) In Force December 31,

Current Year Issued During Year Other Changes to




Current Year 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Number of Pols/Certs Amount









1. Alabama ................................ AL ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 2. Alaska ...................................AK ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 3. Arizona ................................. AZ ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 4. Arkansas ............................... AR ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 5. California .............................. CA ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 6. Colorado ............................... CO ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 7. Connecticut ........................... CT ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 8. Delaware ............................... DE ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 9. District of Columbia ............. DC ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 10. Florida.................................... FL ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 11. Georgia .................................GA ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 12. Hawaii.................................... HI ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 13. Idaho ...................................... ID ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 14. Illinois .................................... IL ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 15. Indiana ................................... IN ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 16. Iowa ....................................... IA ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 17. Kansas................................... KS ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 18. Kentucky ...............................KY ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 19. Louisiana .............................. LA ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 20. Maine ................................... ME ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 21. Maryland .............................. MD ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 22. Massachusetts ...................... MA ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 23. Michigan ............................... MI ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 24. Minnesota ............................ MN ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 25. Mississippi ............................MS ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 26. Missouri ............................... MO ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 27. Montana ............................... MT ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 28. Nebraska ............................... NE ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 29. Nevada ..................................NV ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 30. New Hampshire ....................NH ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 31. New Jersey ............................. NJ ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 32. New Mexico ........................ NM ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 33. New York .............................NY ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 34. North Carolina ...................... NC ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 35. North Dakota .......................ND ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 36. Ohio ......................................OH ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 37. Oklahoma .............................OK ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 38. Oregon .................................. OR ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 39. Pennsylvania ......................... PA ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 40. Rhode Island .......................... RI ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 41. South Carolina ...................... SC ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 42. South Dakota ........................ SD ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 43. Tennessee ............................ TN ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 44. Texas..................................... TX ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 45. Utah ...................................... UT ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 46. Vermont ................................ VT ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 47. Virginia .................................VA ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 48. Washington .......................... WA ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 49. West Virginia ....................... WV ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 50. Wisconsin ............................. WI ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 51. Wyoming ............................. WY ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 52. American Samoa ................... AS ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 53. Guam ....................................GU ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 54. Puerto Rico ........................... PR ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 55. US Virgin Islands .................. VI ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 56. Northern Mariana Islands .....MP ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 57. Canada ............................... CAN ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 58. Aggregate Other Alien .......... OT 59. Total

Attachment I


EXHIBIT OF SETTLED DURING CURRENT YEAR Allocated by States and Territories

By Payment in Full By payment on Compromised Claims Totals Paid Reduction by Compromise Amount Rejected Total Settled During Current Year 1 2 3 4 5 6 7 8 9 10 11 12

Pols\Certs Amount Pols\Certs Amount Pols\Certs (Col 1+3)

Amount (Col 2+4) Pols\Certs Amount Pols\Certs Amount Pols\Certs

Amount (Col 6+8+10)

1. Alabama ............................... AL ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 2. Alaska .................................. AK ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 3. Arizona ................................. AZ ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 4. Arkansas ............................... AR ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 5. California .............................. CA ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 6. Colorado ............................... CO ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 7. Connecticut .......................... CT ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 8. Delaware .............................. DE ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 9. District of Columbia ............. DC ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 10. Florida ...................................FL ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 11. Georgia ................................ GA ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 12. Hawaii ................................... HI ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 13. Idaho ...................................... ID ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 14. Illinois ................................... IL ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 15. Indiana ................................... IN ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 16. Iowa ....................................... IA ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 17. Kansas .................................. KS ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 18. Kentucky ............................. KY ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 19. Louisiana .............................. LA ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 20. Maine ................................... ME ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 21. Maryland ............................. MD ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 22. Massachusetts ...................... MA ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 23. Michigan .............................. MI ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 24. Minnesota ............................ MN ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 25. Mississippi ........................... MS ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 26. Missouri ............................... MO ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 27. Montana ............................... MT ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 28. Nebraska ............................... NE ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 29. Nevada ................................. NV ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 30. New Hampshire ................... NH ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 31. New Jersey ............................ NJ ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 32. New Mexico ........................ NM ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 33. New York ............................ NY ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 34. North Carolina ...................... NC ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 35. North Dakota ...................... ND ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 36. Ohio ..................................... OH ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 37. Oklahoma ............................ OK ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 38. Oregon .................................. OR ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 39. Pennsylvania ........................ PA ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 40. Rhode Island .......................... RI ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 41. South Carolina ...................... SC ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 42. South Dakota ........................ SD ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 43. Tennessee ............................ TN ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 44. Texas .................................... TX ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 45. Utah ...................................... UT ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 46. Vermont ................................ VT ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 47. Virginia ............................... VA ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 48. Washington .........................WA ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 49. West Virginia ......................WV ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 50. Wisconsin ............................. WI ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 51. Wyoming .............................WY ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 52. American Samoa .................. AS ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 53. Guam ................................... GU ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 54. Puerto Rico ........................... PR ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 55. US Virgin Islands .................. VI ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 56. Northern Mariana Islands .... MP ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 57. Canada ............................... CAN ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 58. Aggregate Other Alien ......... OT ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 59. Total

Attachment I


ANNUAL STATEMENT BLANK – HEALTH (LIFE SUPPLEMENT) DIRECT BUSINESS IN THE STATE OF DURING THE YEAR .

NAIC Group Code........................ LIFE INSURANCE NAIC Company Code................................

DIRECT PREMIUMS AND ANNUITY CONSIDERATIONS

1

Ordinary

2 Credit Life

(Group and Individual)

3

Group

4

Industrial

5

Total 1. Life insurance ...............................................................................................2. Annuity considerations .................................................................................3. Deposit-type contract funds ..........................................................................4. Other considerations .....................................................................................5. Totals (Sum of Lines 1 to 4)

................................................ ................................................ ................................................ ................................................

................................................ ................................................

XXX ................................................

............................................... ............................................... ............................................... ...............................................

................................................ ................................................

XXX ................................................

................................................ ................................................ ................................................ ................................................

DIRECT DIVIDENDS TO POLICYHOLDERS/REFUNDS TO MEMBERS

Life insurance: 6.1 Paid in cash or left on deposit ......................................................................6.2 Applied to pay renewal premiums ................................................................6.3 Applied to provide paid-up additions or shorten the endowment or

premium-paying period ................................................................................6.4 Other .............................................................................................................6.5 Totals (Sum of Lines 6.1 to 6.4) ...................................................................Annuities: 7.1 Paid in cash or left on deposit ......................................................................7.2 Applied to provide paid-up annuities ...........................................................7.3 Other .............................................................................................................7.4 Totals (Sum of Lines 7.1 to 7.3) ...................................................................8. Grand Totals (Lines 6.5 + 7.4)

................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................

................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................

............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ...............................................

................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................

................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................

DIRECT CLAIMS AND BENEFITS PAID 9. Death benefits ...............................................................................................10. Matured endowments ...................................................................................11. Annuity benefits ...........................................................................................12. Surrender values and withdrawals for life contracts .....................................13. Aggregate write-ins for miscellaneous direct claims and benefits paid .......14. All other benefits, except accident and health ..............................................15. Totals

................................................ ................................................ ................................................ ................................................ ................................................ ................................................

................................................ ................................................ ................................................ ................................................ ................................................ ................................................

............................................... ............................................... ............................................... ............................................... ............................................... ...............................................

................................................ ................................................ ................................................ ................................................ ................................................ ................................................

................................................ ................................................ ................................................ ................................................ ................................................ ................................................

DETAILS OF WRITE-INS 1301. ......................................................................................................................1302. ......................................................................................................................1303. ......................................................................................................................1398. Summary of remaining write-ins for Line 13 from overflow page ..............1399. Total (Lines 1301 through 1303 + 1398) (Line 13 above)

................................................ ................................................ ................................................ ................................................

................................................ ................................................ ................................................ ................................................

............................................... ............................................... ............................................... ...............................................

................................................ ................................................ ................................................ ................................................

................................................ ................................................ ................................................ ................................................

Ordinary

Credit Life (Group and Individual)

Group

Industrial

Total

DIRECT DEATH BENEFITS AND MATURED ENDOWMENTS INCURRED

1


2

Amount

3 No. of Ind. Pols. & Gr.

Certifs.

4

Amount

5

No. of Certifs.

6

Amount

7


8

Amount

9


10

Amount

16. Unpaid December 31, prior year ..................................................................17. Incurred during current year .........................................................................

Settled during current year: 18.1 By payment in full ........................................................................................18.2 By payment on compromised claims ...........................................................18.3 Totals paid ....................................................................................................18.4 Reduction by compromise ............................................................................18.5 Amount rejected ...........................................................................................18.6 Total settlements ..........................................................................................19. Unpaid Dec. 31, current year (Lines 16 + 17 - 18.6)

.................... .................... .................... .................... .................... .................... .................... ....................

.................... .................... .................... .................... .................... .................... .................... ....................

.................... .................... .................... .................... .................... .................... .................... ....................

.................... .................... .................... .................... .................... .................... .................... ....................

................... ................... ................... ................... ................... ................... ................... ...................

.................... .................... .................... .................... .................... .................... .................... ....................

.................... .................... .................... .................... .................... .................... .................... ....................

................... ................... ................... ................... ................... ................... ................... ...................

.................... .................... .................... .................... .................... .................... .................... ....................

.................... .................... .................... .................... .................... .................... .................... ....................

POLICY EXHIBIT

No. of Policies

20. In force December 31, prior year .................................................................21. Issued during year ........................................................................................22. Other changes to in force (Net) ....................................................................23. In force December 31 of current year

.................... .................... ....................

.................... .................... ....................

.................... .................... ....................

(a) ................ .................... .................... (a)

................... ................... ...................

.................... .................... ....................

.................... .................... ....................

................... ................... ...................

.................... .................... ....................

.................... .................... ....................

(a) Includes Individual Credit Life Insurance prior year $...................................................................., current year $....................................................................... Includes Group Credit Life Insurance Loans less than or equal to 60 months at issue, prior year $...................................................................., current year $................................................................... Loans greater than 60 months at issue BUT NOT GREATER THAN 120 MONTHS prior year $................................................................., current year $................................................................

ACCIDENT AND HEALTH INSURANCE

1

Direct Premiums

2 Direct

Premiums Earned

3 Policyholder Dividends

Paid, Refunds to Members or Credited on

Direct Business

4 Direct Losses Paid

5 Direct Losses

Incurred

24. Group policies (b) ...........................................................................................24.1 Federal Employees Health Benefits Plan premium (b) ..................................24.2 Credit (Group and Individual) ........................................................................24.3 Collectively renewable policies/certificates (b)..............................................24.4 Medicare Title XVIII exempt from state taxes or fees ................................... Other Individual Policies: 25.1 Non-cancelable (b) .........................................................................................25.2 Guaranteed renewable (b) .............................................................................25.3 Non-renewable for stated reasons only (b) .....................................................25.4 Other accident only ........................................................................................25.5 All other (b) ....................................................................................................25.6 Totals (sum of Lines 25.1 to 25.5) .................................................................26. Totals (Lines 24 + 24.1 + 24.2 + 24.3 + 24.4 + 25.6)

............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ...............................................

................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................ ................................................

............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ...............................................

............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ...............................................

............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ............................................... ...............................................

(b) For health business on indicated lines report: Number of persons insured under PPO managed care products ________________ and number of persons insured under indemnity only products ____________ .

Attachment I


DIRECT BUSINESS IN THE STATE OF DURING THE YEAR

NAIC Group Code…….................. LIFE INSURANCE NAIC Company Code….............................

1 2 Dividends to Policyholders/Refunds to Members Claims and Benefits Paid Death Benefits and Matured

Endowments Incurred Policy Exhibit

3 4 5 6 7 8 9 10 11 12 13 14 15 In Force December 31,

Current Year (b)

Line of Business

Premiums and Annuities

Considerations Other

Considerations Paid in Cash or Left on Deposit

Applied to Pay Renewal

Premiums

Applied to Provide Paid-Up

Additions or Shorten the Endowment

or Premium- Paying Period Other

Total (Col.

3+4+5+6)

Death and Annity

Benefits Matured

Endowments

Surrender Values and

Withdrawals for Life

Contracts All Other Benefits

Total (Sum Columns 8 through 11)

Incurred During Current

Year Total Claims Settlements

Unpaid December. 31, Current Year

16 Number of Policies/

Certificates

17

Amount Individual Life 1. Industrial ....................................... ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ...................... ..................... ...................... ....................... 2. Whole ............................................ ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 3. Term .............................................. ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 4. Indexed ......................................... ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 5. Universal ....................................... ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 6. Universal with Secondary

Guarantees .................................... ........................

.......................

..........................

..........................

..................................

.........................

..........................

..........................

.........................

.........................

..........................

..........................

..........................

.........................

.........................

...........................

...........................

8. Variable ......................................... ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 9. Variable Universal ........................ ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 10. Credit ........................................... ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ....................... (a) 11. Other ............................................ ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 12. Total Individual Life Group Life 13. Whole ............................................ ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 14. Term .............................................. ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 15. Universal ....................................... ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 16. Variable ......................................... ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 17. Variable Universal ........................ ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 18. Credit ............................................ ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ....................... (a) 19. Other ............................................. ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 20. Total Group Life Individual Annuities 21. Fixed ............................................. ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 22. Indexed ......................................... ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 23. Variable with Guarantees .............. ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 24. Variable without Guarantees ......... ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 25. Life Contingent Payout ................. ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 26. Other ............................................. ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 27. Total Individual Annuities Group Annuities 28. Fixed ............................................. ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 29. Indexed ......................................... ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 30. Variable with Guarantees .............. ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 31. Variable without Guarantees ......... ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 32. Contingent Payout ......................... ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 33. Other ............................................. ........................ ....................... .......................... .......................... .................................. ......................... .......................... .......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ........................... ........................... 34. Total Group Annuities Accident and Health 35. Comprehensive Individual ............ ........................ ....................... .......................... .......................... .................................. ......................... .......................... XXX XXX XXX .......................... .......................... XXX XXX XXX ........................... ........................... 36. Comprehensive Group .................. ........................ ....................... .......................... .......................... .................................. ......................... .......................... XXX XXX XXX .......................... .......................... XXX XXX XXX ........................... ........................... 37. Medicare Supplement ................... ........................ ....................... .......................... .......................... .................................. ......................... .......................... XXX XXX XXX .......................... .......................... XXX XXX XXX ........................... ........................... 38. Dental Only ................................... ........................ ....................... .......................... .......................... .................................. ......................... .......................... XXX XXX XXX .......................... .......................... XXX XXX XXX ........................... ........................... 39. Vision Only ................................... ........................ ....................... .......................... .......................... .................................. ......................... .......................... XXX XXX XXX .......................... .......................... XXX XXX XXX ........................... ........................... 40. Federal Employees Health

Benefits Plan ................................. ........................

.......................

..........................

..........................

..................................

.........................

..........................

XXX

XXX

XXX

..........................

..........................

XXX

XXX

XXX

...........................

...........................

41. Title XVIII Medicare (d) .............. .................... (e) ....................... .......................... .......................... .................................. ......................... .......................... XXX XXX XXX .......................... .......................... XXX XXX XXX ........................... ........................... 42. Title XIX Medicaid ....................... ........................ ....................... .......................... .......................... .................................. ......................... .......................... XXX XXX XXX .......................... .......................... XXX XXX XXX ........................... ........................... 43. Credit A&H................................... ........................ ....................... .......................... .......................... .................................. ......................... .......................... XXX XXX XXX .......................... .......................... XXX XXX XXX ........................... ........................... 44. Disability Income .......................... ........................ ....................... .......................... .......................... .................................. ......................... .......................... XXX XXX XXX .......................... .......................... XXX XXX XXX ........................... ........................... 45. Long-Term Care ........................... ........................ ....................... .......................... .......................... .................................. ......................... .......................... XXX XXX XXX .......................... .......................... XXX XXX XXX ........................... ........................... 46. Other Health .................................. ........................ ....................... .......................... .......................... .................................. ......................... .......................... XXX XXX XXX .......................... .......................... XXX XXX XXX ........................... ........................... 47. Total Accident and Health XXX XXX XXX XXX XXX XXX 48. TOTAL (c)

(a) Includes Group Credit Life Insurance Loans less than or equal to 60 months at issue, prior year $........................., current year $.......................... Loans greater than 60 months at issue BUT NOT GREATER THAN 120 MONTHS prior year $........................., current year $.........................

(b) ..Corporate Owned Life Insurance/BOLI: 1) Number of policies: .........................2) covering number of lives: .........................3) face amount: .........................

(c) ..Deposit-Type Contract Considerations NOT included in Total Premiums and Annuities Considerations: Individual: $......................... Group: $......................... Total: $.........................

(d) For health business: number of persons insured under PPO managed care products ......................... and number of persons insured under indemnity only products.........................

(e) For health premiums written: amount of Medicare Title XVIII exempt from state taxes or fees $.........................

Attachment I



Life Contracts Annuity Contracts Accident and Health Contracts

Issued During Year Other Changes to






Current Year 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18










1. Alabama ................................ AL ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 2. Alaska ...................................AK ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 3. Arizona ................................. AZ ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 4. Arkansas ............................... AR ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 5. California .............................. CA ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 6. Colorado ............................... CO ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 7. Connecticut ........................... CT ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 8. Delaware ............................... DE ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 9. District of Columbia ............. DC ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 10. Florida.................................... FL ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 11. Georgia .................................GA ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 12. Hawaii.................................... HI ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 13. Idaho ...................................... ID ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 14. Illinois .................................... IL ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 15. Indiana ................................... IN ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 16. Iowa ....................................... IA ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 17. Kansas................................... KS ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 18. Kentucky ...............................KY ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 19. Louisiana .............................. LA ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 20. Maine ................................... ME ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 21. Maryland .............................. MD ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 22. Massachusetts ...................... MA ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 23. Michigan ............................... MI ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 24. Minnesota ............................ MN ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 25. Mississippi ............................MS ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 26. Missouri ............................... MO ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 27. Montana ............................... MT ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 28. Nebraska ............................... NE ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 29. Nevada ..................................NV ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 30. New Hampshire ....................NH ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 31. New Jersey ............................. NJ ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 32. New Mexico ........................ NM ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 33. New York .............................NY ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 34. North Carolina ...................... NC ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 35. North Dakota .......................ND ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 36. Ohio ......................................OH ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 37. Oklahoma .............................OK ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 38. Oregon .................................. OR ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 39. Pennsylvania ......................... PA ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 40. Rhode Island .......................... RI ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 41. South Carolina ...................... SC ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 42. South Dakota ........................ SD ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 43. Tennessee ............................ TN ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 44. Texas..................................... TX ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 45. Utah ...................................... UT ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 46. Vermont ................................ VT ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 47. Virginia .................................VA ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 48. Washington .......................... WA ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 49. West Virginia ....................... WV ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 50. Wisconsin ............................. WI ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 51. Wyoming ............................. WY ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 52. American Samoa ................... AS ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 53. Guam ....................................GU ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 54. Puerto Rico ........................... PR ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 55. US Virgin Islands .................. VI ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 56. Northern Mariana Islands .....MP ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 57. Canada ............................... CAN ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... ....................... ....................... ....................... ....................... ....................... ....................... 58. Aggregate Other Alien .......... OT 59. Total

Attachment I



By Payment in Full By Payment on Compromised Claims Totals Paid Reduction by Compromise Amount Rejected Total Settled During Current Year 1 2 3 4 5 6 7 8 9 10 11 12

Pols\Certs Amount Pols\Certs Amount Pols\Certs (Col 1+3)

Amount (Col 2+4) Pols\Certs Amount Pols\Certs Amount Pols\Certs

Amount (Col 6+8+10)

1. Alabama ............................... AL ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 2. Alaska .................................. AK ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 3. Arizona ................................. AZ ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 4. Arkansas ............................... AR ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 5. California .............................. CA ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 6. Colorado ............................... CO ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 7. Connecticut .......................... CT ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 8. Delaware .............................. DE ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 9. District of Columbia ............. DC ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 10. Florida ...................................FL ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 11. Georgia ................................ GA ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 12. Hawaii ................................... HI ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 13. Idaho ...................................... ID ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 14. Illinois ................................... IL ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 15. Indiana ................................... IN ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 16. Iowa ....................................... IA ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 17. Kansas .................................. KS ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 18. Kentucky ............................. KY ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 19. Louisiana .............................. LA ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 20. Maine ................................... ME ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 21. Maryland ............................. MD ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 22. Massachusetts ...................... MA ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 23. Michigan .............................. MI ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 24. Minnesota ............................ MN ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 25. Mississippi ........................... MS ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 26. Missouri ............................... MO ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 27. Montana ............................... MT ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 28. Nebraska ............................... NE ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 29. Nevada ................................. NV ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 30. New Hampshire ................... NH ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 31. New Jersey ............................ NJ ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 32. New Mexico ........................ NM ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 33. New York ............................ NY ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 34. North Carolina ...................... NC ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 35. North Dakota ...................... ND ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 36. Ohio ..................................... OH ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 37. Oklahoma ............................ OK ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 38. Oregon .................................. OR ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 39. Pennsylvania ........................ PA ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 40. Rhode Island .......................... RI ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 41. South Carolina ...................... SC ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 42. South Dakota ........................ SD ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 43. Tennessee ............................ TN ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 44. Texas .................................... TX ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 45. Utah ...................................... UT ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 46. Vermont ................................ VT ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 47. Virginia ............................... VA ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 48. Washington .........................WA ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 49. West Virginia ......................WV ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 50. Wisconsin ............................. WI ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 51. Wyoming .............................WY ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 52. American Samoa .................. AS ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 53. Guam ................................... GU ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 54. Puerto Rico ........................... PR ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 55. US Virgin Islands .................. VI ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 56. Northern Mariana Islands .... MP ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 57. Canada ............................... CAN ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 58. Aggregate Other Alien ......... OT ....................... ........................ ............................... ........................ ....................... ........................ ........................ ........................ ........................ ....................... ........................ ........................ 59. Total


Attachment I



Attachment J




DATE: 10/21/2021

CONTACT PERSON:

TELEPHONE:


NAME: Steve Drutz



ADDRESS:






[ X ] ANNUAL STATEMENT [ X ] INSTRUCTIONS [ X ] CROSSCHECKS [ X ] QUARTERLY STATEMENT [ X ] BLANK

[ ] Life, Accident & Health/Fraternal [ ] Separate Accounts [ ] Title [ ] Property/Casualty [ ] Protected Cell [ ] Other _______________________ [ X ] Health [ ] Health (Life Supplement)


IDENTIFICATION OF ITEM(S) TO CHANGE Add columns and lines to U&I (Parts 1, 2, 2A, 2B and 2D) and the Exhibit of Premiums, Enrollment and Utilization in the annual statement bring the lines of business reporting in line with Life/Fraternal and Property. Add columns and lines to the Exhibit of Premiums, Enrollment and Utilization and U&I Analysis of Claims Unpaid quarterly pages. The appropriate adjustments to the instructions are also being made.

REASON, JUSTIFICATION FOR AND/OR BENEFIT OF CHANGE** The purpose of this proposal is to bring consistency in lines of business reporting across all statement types that report health business. This proposal brings the Health Statement in line with Life/Fraternal and Property Statements.


Attachment J




PART 1 – PREMIUMS Written premium is defined as the contractually determined amount charged by the reporting entity to the policyholder for the effective period of the contract based on the expectation of risk, policy benefits, and expenses associated with the coverage provided by the terms of the insurance contract. For health contracts without fixed contract periods, premiums written will be equal to the amount collected during the reporting period plus uncollected premiums at the end of the period less uncollected premiums at the beginning of the period. Column 1 – Direct Business

Include: Experience rating refunds and return retrospective premiums. Deduct any experience rating refunds and return retrospective premiums paid. Refer to SSAP No. 66—Retrospectively Rated Contracts for accounting guidance.

Accrued return premium adjustments for contracts subject to redetermination.

Column 4 – Net Premium Income

For companies that record premium on a cash basis, make adjustments for uncollected premiums at the beginning and end of the year to reflect premiums on a written basis.

Line 1 – Comprehensive (Hospital & Medical) – Individual Line 2 – Comprehensive (Hospital & Medical) – Group

Include: Policies providing for medical coverages including hospital, surgical and major medical. Include State Children’s Health Insurance Program (SCHIP) Medicaid Program (Title XXI), risk contracts.


administrative services contracts (ASC), federal employees health benefit plan (FEHBP) premiums, medical only policies, Medicare (Title XVIII) and Medicaid (Title XIX) risk contracts, Medicare Supplement, Vision only and Dental only business.

Line 23 – Medicare Supplement


Exclude: Revenue as a result of an arrangement between the reporting entity and the

Centers for Medicare & Medicaid Services (CMS), on a cost or risk basis, for services to a Medicare beneficiary.

Line 34 – Dental Only

Include: Premiums for policies providing for dental only coverage issued as stand alone dental or as a rider to a medical policy that is not related to the medical policy through deductibles or out-of-pocket limits.

Line 45 – Vision Only

Include: Premiums for policies providing for vision only coverage issued as stand alone vision or as a rider to a medical policy that is not related to the medical policy through deductibles or out-of-pocket limits.

}

Attachment J


Line 56 – Federal Employees Health Benefits Plan (FEHBP)

Include: Net premiums written attributable to the FEHBP. Line 67 – Title XVIII - Medicare

Include: Revenue as a result of a risk arrangement between the reporting entity and the Centers for Medicare & Medicaid Services (CMS), for services to a Medicare beneficiary. Policies providing Medicare Part D Prescription Drug Coverage through a Medicare Advantage product.

Exclude: Medicare Supplement or Medicare wrap-around premiums. Policies providing

stand alone Medicare Part D Prescription Drug Coverage. Line 78 – Title XIX - Medicaid

Include: Revenue resulting from an arrangement between the reporting entity and a Medicaid state agency for services to a Medicaid beneficiary.

Line 10 – Credit A&H


Line 11 – Disability Income


Line 12 – Long-Term Care



Line 812 – Other Health

Include: Other health revenues not included in any other column, including stop loss, disability income and long-term care. Policies providing stand alone Medicare Part D Prescription Drug Coverage.

Exclude: ASO (administrative services only) contracts and ASC (administrative service

contracts). Refer to SSAP No. 47—Uninsured Plans for accounting guidance. Policies providing Medicare Part D Prescription Drug Coverage through a Medicare Advantage product.

Line 913 – Health Subtotal

Column 1 should equal Schedule T, Line 61 sum of Columns 2, 3, 5 and 6.

Attachment J


Line 1014 – Life

Include: Revenue for life insurance.

Column 1 should equal Schedule T, Line 61, Column7. Line 1115 – Property/Casualty

Include: Revenue for property/casualty insurance.

Column 1 should equal Schedule T, Line 61, Column 8.

Attachment J



PART 2 – CLAIMS INCURRED DURING THE YEAR Column 913 – Other Health

Include: Claims incurred for other health lines of business not included in any other column, including stop loss, disability income and long-term care.

Column 1014 – Other Non-health

Include: Claims incurred for life and property/casualty lines of business. Line 1 – Payments During the Year

Report payments net of pharmaceutical rebates collected and risk share amount collected. Refer to SSAP No. 84—Health Care and Government Insured Plan Receivables for accounting guidance.

Line 1.3 should include only those reinsurance recoveries received during the year.

Exclude: Medical incentive pools and bonuses.

Line 2 – Paid Medical Incentive Pools and Bonuses

Equals Underwriting and Investment, Part 2B, Columns 1 and 2, Line 1216.


Line 12 – Incurred Benefits

Line 12.1 = Line 1.1 + Line 3.1 + Line 4.1 – Line 6 – Line 8.1 – Line 9.1

Line 12.2 = Line 1.2 + Line 3.2 + Line 4.2 – Line 8.2 – Line 9.2

Line 12.3 = Line 1.3 + Line 3.3 + Line 4.3 + Line 7 – Line 8.3 – Line 9.3 – Line 11

Line 12.4 = Line 1.4 + Line 3.4 + Line 4.4 – Line 6 – Line 7 – Line 8.4 – Line 9.4 + Line 11 Line 12.1 – Incurred Benefits: Direct

Column 1 minus Column 1014, Line 12.1 should agree with the sum of Lines 9 through 14 on the Statement of Revenue and Expenses.

Line 13 – Incurred Medical Incentive Pools and Bonuses

This should agree with Line 2 + Line 5 – Line 10.

Attachment J



PART 2A – CLAIMS LIABILITY END OF CURRENT YEAR Refer to SSAP No. 55—Unpaid Claims, Losses and Loss Adjustment Expenses for accounting guidance. Include recoverables for anticipated coordination of benefits and subrogation as a reduction to unpaid claims. Column 913 – Other Health

Include: Claims liability for other health lines of business not included in any other column, including stop loss, disability income and long-term care.

Column 1014 – Other Non-health

Include: Claims liability for life and property/casualty lines of business. Line 1 – Reported in Process of Adjustment

Include: Liability for all claims that have been reported to the company on or before December 31 of the current year. Provision for claims of the current year or prior years, if any, reported after that date would be made in Line 2 as Incurred but Unreported. Portions of reported claims for which payments are due after December 31 of the current year are reported in Underwriting and Investment Exhibit, Part 2D, Line 9.

Line 2 – Incurred but Unreported

Except where inapplicable, the reserve included in these lines should be based on past experience, modified to reflect current conditions, such as changes in exposure, claim frequency or severity.

Line 3 – Amounts Withheld from Paid Claims and Capitations

Report the amounts withheld from paid claims and capitations that have not been distributed and the anticipated withholds from estimated incurred but not reported losses.

Line 4.4 – Net Total Claim Liability

This amount should agree to Page 3, Line 1, Column 3.

Attachment J



PART 2B – ANALYSIS OF CLAIMS UNPAID – PRIOR YEAR – NET OF REINSURANCE Claims are to include amounts paid or accrued for capitation, and any other means of payment, for medical or other health care services including, under other medical costs, amounts for occupancy, depreciation and amortization as it relates to medical and hospital expenses. Incentive pool, withhold, and bonus amounts are defined as: amounts to be paid to providers by the Health entity as an incentive to achieve goals such as effective management of care. Some arrangements involve paying an agreed-on amount for each claim, and then paying a bonus at the end of the contract period. Other arrangements involve a set amount to be withheld from each claim, and then paying a portion (which could be none or all) of the withheld amount at the end of the contract period. For arrangements involving amounts withheld, the claim payments should be recorded net of the withhold, and the unpaid withholds should be held as an additional liability until paid or formally retained. The amount due should be supported by signed agreements and the basis for establishing the liability should be documented when determining the amount of this liability. Columns 1 and 2

Enter in Columns 1 and 2, Lines 1 through 812, all payments made during the year. Record actual payments only, net of applicable Coordination of Benefits, deductibles, copayments, pharmaceutical rebates collected, risk share amounts collected, reinsurance, subrogation, and provider discounts. Refer to SSAP No. 84—Health Care and Government Insured Plan Receivables for accounting guidance.

Include in Columns 1 and 2, Line 1014, the portion of current health care receivables balance relating to claims paid in the current year on insured plans. This would not include those health care receivables, such as loans or advances to non-related party hospitals, established as prepaid assets that are not expensed until the related claims have been received from the provider as the claims have not been paid as of the statement date. Refer to SSAP No. 84—Health Care and Government Insured Plan Receivables for accounting guidance.

Include on Line 12 16 actual payments from provider incentive pools and bonus arrangements or supplemental facility settlements (distributions of utilization savings).

All claim payments made relating to service dates prior to the current reporting year should be reported in Column 1. Report in Column 2 all claim payments for service dates in the current reporting year.

Columns 3 and 4

Enter in Columns 3 and 4 all claims related liabilities and reserves held at the end of the current year. This includes liability for both reported and unreported claims and should be net of anticipated reductions for coordination of benefits, deductibles, copayments, provider discounts or reinsurance recoveries on unpaid claims.

Include in Columns 3 and 4, Line 10 14 the portion of current health care receivables of insured plans relating to claims in the process of adjustment, excluding those health care receivables, such as loans or advances to non-related party hospitals, established as prepaid assets that are not expensed until the related claims have been received from the provider. Refer to SSAP No. 84—Health Care and Government Insured Plan Receivables for accounting guidance.

Report on Lines 1 through 8 12 the claims unpaid gross of the actual withholds on paid claims and net of settlement adjustments to prior withholds. Estimated incurred but unreported losses reported on Lines 1 through 8 12 should be calculated in accordance with SSAP No. 54R—Individual and Group Accident and Health Contracts and may include estimations as to return of withhold on claims incurred, but not yet paid. Liability for provider incentive pools and supplemental facility settlements should also be included on Line 1216.

Attachment J


Line 9 13 plus Line 11 15 of Columns 3 and 4 should agree to Underwriting and Investment Exhibit – Part 2A, Column 1, Line 4.4 plus Underwriting and Investment Exhibit – Part 2D, Column 1, Line 14.

Line 9 13 plus Line 1115, Columns 3 and 4 should equal Page 3, Line 1 plus Line 7, Column 3.

Line 1317, Columns 1 through 4, less Column 6 should agree to Page 4, Line 18 plus Line 19, Column 2.

The sum of Columns 3 and 4, Line 13 17 plus 10 14 should agree to the sum of Lines 1, 2 and 7, Page 3, Column 3.

Line 812 – Other Health

Report the unpaid claims for other health business not included in any other line. This category includes all unspecified business written under the Company’s health line of business authority including stop loss as well as business that does not qualify for the Health Statement Test (e.g., disability income and long-term care).

Line 1014 – Health Care Receivables

This line is based on the gross health care receivable, not just the admitted portion.

Columns 1 and 2 report the amounts of health care receivables associated with claims paid during the year, excluding those health care receivables, such as loans or advances to non-related party hospitals, established as prepaid assets that are not expensed until the related claims have been received from the provider.

Columns 3 and 4 report the health care receivable amount attributable to those claims remaining unpaid as of the reporting date. This will include those amounts of pharmaceutical rebates that are estimated in accordance with SSAP No. 84—Health Care and Government Insured Plan Receivables guidelines.

The sum of Columns 1 through 4 on the Underwriting and Investment Exhibit, Part 2B, Line 10 14 should equal the health care receivables on Exhibit 3, Column 6 plus Column 7, excluding those health care receivables, such as loans or advances to non-related party hospitals, established as prepaid assets that are not expensed until the related claims have been received from the provider. If health care receivables reported on Underwriting and Investment Exhibit, Part 2B are affected by reinsurance, then the sum of Column 1 through Column 4 may be different from the amounts of health care receivables reported on Exhibit 3, which are gross of reinsurance.

If health care receivables are not affected by reinsurance, then Line 1014, Column 1 through Column 4 should be no more than Exhibit 3, Line 0799999, Column 6 plus Column 7 and be no less than to Exhibit 3, Line 0799999, Column 6 plus Column 7 minus Exhibit 3, Line 0399999, Column 6 plus Column 7. If health care receivables are affected by reinsurance, then Line 1014, Column 1 through Column 4 should be more/less than Exhibit 3, Line 0799999, Columns 6 plus 7 minus Exhibit 3, Line 0399999, Column 6 and Column 7.

Column 6 reports the amounts of prior year health care receivables, excluding those health care receivables, such as loans or advances to non-related party hospitals, established as prepaid assets that are not expensed until the related claims have been received from the provider.

Footnote (a) Line 10 14 reports those health care receivables, such as loans or advances to non-related party hospitals, established as prepaid assets that are not expensed until the related claims have been received from the provider.

Line 1115 – Other Non-health

Report the unpaid claims for life and property/casualty business.

Line 1216 – Medical Incentive Pools and Bonus Amounts

Include disbursements for incentive pool and bonus amounts in Column 1 and 2. Include liability for incentive pool and bonus amounts in Column 3 and 4.

Attachment J



PART 2D – AGGREGATE RESERVE FOR ACCIDENT AND HEALTH CONTRACTS ONLY Exclude reserves or other amounts relating to uninsured accident and health plans and the uninsured portion of partially insured accident and health plans from this exhibit. Column 913 – Other

Include: Stop loss, disability income and long-term care. Line 1 – Unearned Premium Reserves



Details of Write-ins Aggregated on Line 5 for Other Policy Reserves

List separately all policy reserves for which there is no pre-printed line.

Include: Accrued return premium adjustments for contracts subject to redetermination. Details of Write-ins Aggregated on Line 11 for Other Claim Reserves

List separately all claim reserves for which there is no pre-printed line.

Attachment J


EXHIBIT OF PREMIUMS, ENROLLMENT AND UTILIZATION A schedule must be prepared and submitted to the state of domicile for each jurisdiction in which the company has written direct business, or has direct amounts paid, incurred or unpaid for provisions of health care services. In addition, a schedule must be prepared and submitted that contains the grand total (GT) for the company. To other states in which the company is licensed it should submit a schedule for that state. Written premium is defined as the contractually determined amount charged by the reporting entity to the policyholder for the effective period of the contract based on the expectation of risk, policy benefits, and expenses associated with the coverage provided by the terms of the insurance contract. For health contracts without fixed contract periods, premiums written will be equal to the amount collected during the reporting period plus uncollected premiums at the end of the period less uncollected premiums at the beginning of the period. Column 1 – Total

Include: All members. Columns 2 through 1013 – Lines of Business

See Appendix – Definitions of Lines of Business in determining with which source information is associated. Stop loss, disability income and long-term care are is to be included in the Other column.


Include: Medicare Supplement contracts as defined by the NAIC Medicare Supplement Insurance Minimum Standards Model Act (#650) and Model Regulation to Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act (#651).

Contracts sold primarily to Medicare eligible persons and designed to coordinate with Medicare but that are exempt from the NAIC Medicare Supplement Insurance Minimum Standards Model Act (#650) and Model Regulation to Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act (#651).

Column 8 – Title XVIII Medicare

Include only amounts collected from the Federal Government for Medicare benefits and the amounts collected from enrollees over and above that collected from the Federal Government as authorized under Title XVIII.

Column 1013 – Other

Include: Policies providing stand-alone Medicare Part D Prescription Drug Coverage. Column 14 – Other Non-health

Include: Claims incurred for life and property/casualty lines of business. Line 1 – Total Members at End of Prior Year

A member is a person who has been enrolled as a subscriber, or an eligible dependent of a subscriber, and for whom the reporting entity has accepted the responsibility for the provision of basic health services as provided by contract.


Attachment J


Line 12 – Health Premiums Written

Include: Direct premiums written.

Column 1 should equal Underwriting and Investment Exhibit, Part 1, Column 1, Line 913. Line 13 – Life Premiums Direct

Include: Direct premiums and annuity considerations for life contracts excluding reinsurance assumed and without deduction of reinsurance ceded.

Column 1 should equal Underwriting and Investment Exhibit, Part 1, Column 1, Line 1014.

Line 14 – Property/Casualty Premiums Written

Include: Direct premiums for property and casualty lines of business excluding reinsurance assumed and without deduction of reinsurance ceded.

Column 1 should equal Underwriting and Investment Exhibit, Part 1, Column 1, Line 1115.

Line 15 – Health Premiums Earned

Include: Direct written premium plus the change in unearned premium reserves and reserve for rate credits.

Sum of General Interrogatories Part 2, Lines 1.61, 1.64, 1.71 and 1.74 should equal Column 4, Grand Total Exhibit of Premiums, Enrollment and Utilization page.


Footnote (a) – Complete the information regarding number of persons covered under PPO managed care products and

number of persons covered under indemnity only products. Include in PPO business health insurance products that provide access to higher level of benefits whenever participating provider networks are used. This will include all blended products whereby an indemnity product is sold and issued in conjunction with an HMO product. Health business includes all business equivalent to that included in the health blank.

Footnote (b) – Report Medicare Title XVIII premiums that are exempted from state taxes or other fees by

Section 1854(g) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. This includes but is not limited to premiums written under a Medicare Advantage product, a Medicare PPO product, or a stand-alone Medicare part D product.

Attachment J


QUARTERLY STATEMENT INSTRUCTIONS – HEALTH

EXHIBIT OF PREMIUMS, ENROLLMENT AND UTILIZATION


Column 1 – Total

Include: All members.

Columns 2 through 1013 – Lines of Business

See Annual Statement Appendix – Definitions of Lines of Business and Product Lines in determining with which source information is associated. Stop loss, disability income and long-term care are is to be included in the Other column.


Include: Medicare Supplement contracts as defined by the NAIC Medicare Supplement Insurance Minimum Standards Model Act (#650) and Model Regulation to Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act (#651).

Contracts sold primarily to Medicare eligible persons and designed to coordinate with Medicare but that are exempt from the NAIC Medicare Supplement Insurance Minimum Standards Model Act (#650) and Model Regulation to Implement the NAIC Medicare Supplement Insurance Minimum Standards Model Act (#651).

Column 8 – Title XVIII Medicare

Include only amounts collected from the Federal Government for Medicare benefits and the amounts collected from enrollees over and above that collected from the Federal Government as authorized under Title XVIII. Policies providing Medicare Part D Prescription Drug Coverage through a Medicare Advantage product.

Column 1013 – Other

Include: Policies providing stand-alone Medicare Part D Prescription Drug Coverage. Column 14 – Other Non-health

Include: Claims incurred for life and property/casualty lines of business.

Line 1 – Total Members at End of Prior Year

A member is a person who has been enrolled as a subscriber, or an eligible dependent of a subscriber, and for whom the reporting entity has accepted the responsibility for the provision of basic health services as provided by contract.

Line 2 – Total Members at End of First Quarter

Show total members (cumulative) at the end of the quarter.


Attachment J



ANALYSIS OF CLAIMS UNPAID – PRIOR YEAR NET OF REINSURANCE Information should be reported for current year-to-date. Refer to SSAP No. 54R—Individual and Group Accident and Health Contracts, and SSAP No. 66—Retrospectively Rated Contracts, for accounting guidance. Exclude: From the appropriate lines and columns, those amounts attributable to the Federal Employees Health

Benefit Plan (FEHBP) that are exempted from state taxes or other fees by Section 8909(f)(1) of Title 5 of the United States Code.

Amounts attributable to uninsured plans and the uninsured portion of partially insured plans.

Claims are to include amounts paid or accrued for capitation, and any other means of payment, for medical or other health care services including, under other medical costs, amounts for occupancy, depreciation and amortization as it relates to medical and hospital expenses. Incentive pool, withhold and bonus amounts are defined as amounts to be paid to providers by the Health entity as an incentive to achieve goals such as effective management of care. Some arrangements involve paying an agreed-on amount for each claim and then paying a bonus at the end of the contract period. Other arrangements involve a set amount to be withheld from each claim and then paying a portion (which could be none or all) of the withheld amount at the end of the contract period. For arrangements involving amounts withheld, the claim payments should be recorded net of the withhold, and the unpaid withholds should be held as an additional liability until paid or formally retained. The amount due should be supported by signed agreements and the basis for establishing the liability should be documented when determining the amount of this liability. Columns 1 and 2: Enter in Columns 1 and 2, Lines 1 through 8 12 and 1115, all payments made year-to-date. Record actual payments only, net of applicable Coordination of Benefits, deductibles, copayments, pharmaceutical rebates collected, risk share amounts collected, reinsurance, subrogation and provider discounts. Refer to SSAP No. 84—Health Care and Government Insured Plans Receivables, for accounting guidance. Include in Columns 1 and 2, Line 1014, the current health care receivables balance relating to claims paid year-to-date on insured plans. Refer to SSAP No. 84—Health Care and Government Insured Plans Receivables, for accounting guidance. Include on Line 12 16 actual payments from provider incentive pools and bonus arrangements or supplemental facility settlements (distributions of utilization savings). All claim payments made relating to service dates prior to the current reporting year should be reported in Column 1. Report in Column 2 all claim payments for service dates in the current reporting year. Columns 3 and 4: Enter in Columns 3 and 4 all claims related liabilities and reserves held at the end of the current quarter. This includes liability for both reported and unreported claims and should be net of anticipated reductions for coordination of benefits, deductibles, copayments, provider discounts or reinsurance recoveries. Included in Columns 3 and 4, Line 10 14 current health care receivables of insured plans relating to claims in the process of adjustment. Refer to SSAP No. 84—Health Care and Government Insured Plans Receivables, for accounting guidance.

Attachment J


Report on Line 1 through 8 12 and 1115, the claims unpaid gross of the actual withholds on paid claims and net of settlement adjustments to prior withholds. Estimated incurred but unreported losses reported on Lines 1 through 8 12 should be calculated in accordance with SSAP No. 54R—Individual and Group Accident and Health Contracts and may include estimations as to return of withhold on claims incurred, but not yet paid. Liability for provider incentive pools and supplemental facility settlements should also be included on Line 1216. Line 9 13 plus Line 1115, Column 3 and 4 should equal Page 3, Line 1 plus Line 7, Column 3. Line 1317, Columns 1 through 4, less Column 6 should agree to Page 4, Line 18 plus Line 19, Column 2. The sum of Columns 3 and 4, Line 13 17 plus 10 14 should agree to the sum of Lines 1, 2 and 7, Page 3, Column 3. Line 812 – Other Health

Report the unpaid claims for other health business not included in any other line. This category includes all unspecified business written under the Company’s health line of business authority, including stop loss as well as business that does not qualify for the Health Statement Test (e.g., disability income and long-term care).

Line 1014 – Health Care Receivables

This line is based on the gross health care receivable, not just the admitted portion.

Columns 1 and 2 report the amounts of health care receivables associated with claims paid year-to-date.

Columns 3 and 4 report the health care receivable amount attributable to those claims remaining unpaid as of the end of the current quarter. This will include those amounts of pharmaceutical rebates that are estimated in accordance with SSAP No. 84—Health Care and Government Insured Plans Receivables, guidelines.

Line 1115 – Other Non-health

Report the unpaid claims for life and property/casualty business. Line 1216 – Medical Incentive Pools and Bonus Amounts

Include disbursements for incentive pool and bonus amounts in Column 1 and 2. Include liability for incentive pool and bonus amounts in Column 3 and 4.

Attachment J


ANNUAL STATEMENT BLANK – HEALTH

UNDERWRITING AND INVESTMENT EXHIBIT PART 1 – PREMIUMS

Line of

Business

1

Direct Business

2

Reinsurance Assumed

3

Reinsurance Ceded

4 Net

Premium Income

(Cols. 1+2-3) 1. Comprehensive (hospital and medical) Individual ........................... .............................................................. .............................................................. ............................................................. .............................................................. 2. Comprehensive (hospital and medical) Group ................................. .............................................................. .............................................................. ............................................................. .............................................................. 23. Medicare Supplement ........................................................................ .............................................................. .............................................................. ............................................................. .............................................................. 34. Dental only ........................................................................................ .............................................................. .............................................................. ............................................................. .............................................................. 45. Vision only ........................................................................................ .............................................................. .............................................................. ............................................................. .............................................................. 56. Federal Employees Health Benefits Plan .......................................... .............................................................. .............................................................. ............................................................. .............................................................. 67. Title XVIII – Medicare ..................................................................... .............................................................. .............................................................. ............................................................. .............................................................. 78. Title XIX – Medicaid ........................................................................ .............................................................. .............................................................. ............................................................. .............................................................. 9. Credit A&H ....................................................................................... .............................................................. .............................................................. ............................................................. .............................................................. 10. Disability Income .............................................................................. .............................................................. .............................................................. ............................................................. .............................................................. 11. Long-Term Care ................................................................................ .............................................................. .............................................................. ............................................................. .............................................................. 812. Other health ....................................................................................... .............................................................. .............................................................. ............................................................. .............................................................. 913. Health subtotal (Lines 1 through 812) .............................................. .............................................................. .............................................................. ............................................................. .............................................................. 1014. Life .................................................................................................... .............................................................. .............................................................. ............................................................. .............................................................. 1115. Property/casualty ............................................................................... .............................................................. .............................................................. ............................................................. .............................................................. 1216. Totals (Lines 9 13 to 1115)

Attachment J


UNDERWRITING AND INVESTMENT EXHIBIT PART 2 – CLAIMS INCURRED DURING THE YEAR

1 Comprehensive

(Hospital & Medical2 34 45 56 67 78 89 10 11 13 913 1014

2 3

Total

Comprehensive (Hospital &



Federal Employees




Disability Income Long-Term Care Other Health

Other Non-Health

1. Payments during the year: 1.1 Direct ....................................................................................... 1.2 Reinsurance assumed .............................................................. 1.3 Reinsurance ceded ................................................................... 1.4 Net ........................................................................................... 2. Paid medical incentive pools and bonuses ........................................................... 3. Claim liability December 31, current year from Part 2A: 3.1 Direct ....................................................................................... 3.2 Reinsurance assumed ..............................................................

3.3 Reinsurance ceded ...................................................................3.4 Net ...........................................................................................

4. Claim reserve December 31, current year from Part 2D: 4.1 Direct ....................................................................................... 4.2 Reinsurance assumed .............................................................. 4.3 Reinsurance ceded ................................................................... 4.4 Net ........................................................................................... 5. Accrued medical incentive pools and bonuses, current year ............................... 6. Net health care receivables (a) ............................................................................. 7. Amounts recoverable from reinsurers December 31, current year ...................... 8. Claim liability December 31, prior year from Part 2A: 8.1 Direct ...................................................................................... 8.2 Reinsurance assumed ..............................................................


9. Claim reserve December 31, prior year from Part 2D: 9.1 Direct ....................................................................................... 9.2 Reinsurance assumed ..............................................................


10. Accrued medical incentive pools and bonuses, prior year ................................... 11. Amounts recoverable from reinsurers December 31, prior year ...........

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........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................

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12. Incurred benefits: 12.1 Direct ....................................................................................... 12.2 Reinsurance assumed .............................................................. 12.3 Reinsurance ceded ...................................................................

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....................... .......................

....................... .......................

....................... .......................

....................... .......................

......................... .........................

12.4 Net ........................................................................................... 13. Incurred medical incentive pools and bonuses

(a) Excludes $………. loans or advances to providers not yet expensed.

Attachment J


UNDERWRITING AND INVESTMENT EXHIBIT PART 2A – CLAIMS LIABILITY END OF CURRENT YEAR

1 Comprehensive

(Hospital & Medical2 34 45 56 67 78 89 10 11 12 913 1014

2 3

Total




Federal Employees




Disability Income


Other Non-Health

1. Reported in Process of Adjustment: 1.1 Direct ........................................................................ ......................... ........................ .......................... .......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... 1.2 Reinsurance assumed ................................................ ......................... ........................ .......................... .......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... 1.3 Reinsurance ceded .................................................... ......................... ........................ .......................... .......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... 1.4 Net ............................................................................. ......................... ........................ .......................... .......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... .........................

2. Incurred but Unreported:

2.1 Direct ........................................................................ ......................... ........................ .......................... .......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... 2.2 Reinsurance assumed ................................................ ......................... ........................ .......................... .......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... 2.3 Reinsurance ceded .................................................... ......................... ........................ .......................... .......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... 2.4 Net ............................................................................. ......................... ........................ .......................... .......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... .........................

3. Amounts Withheld from Paid Claims and Capitations:

3.1 Direct ........................................................................ ......................... ........................ .......................... .......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... 3.2 Reinsurance assumed ................................................ ......................... ........................ .......................... .......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... 3.3 Reinsurance ceded .................................................... ......................... ........................ .......................... .......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... 3.4 Net ............................................................................. ......................... ........................ .......................... .......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... .........................

4. TOTALS:

4.1 Direct ........................................................................ ......................... ........................ .......................... .......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... 4.2 Reinsurance assumed ................................................ ......................... ........................ .......................... .......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... 4.3 Reinsurance ceded .................................................... ......................... ........................ .......................... .......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... 4.4 Net

Attachment J


UNDERWRITING AND INVESTMENT EXHIBIT PART 2B – ANALYSIS OF CLAIMS UNPAID – PRIOR YEAR-NET OF REINSURANCE

Claims Paid During the Year

Claim Reserve and Claim Liability December 31

of Current Year

5 6

Line of

Business

1 On

Claims Incurred Prior to January 1 of Current Year

2 On

Claims Incurred During the

Year

3 On

Claims Unpaid December 31 of

Prior Year

4 On


Year

Claims

Incurred in Prior Years

(Columns 1 + 3)

Estimated Claim Reserve and

Claim Liability December 31 of

Prior Year 1. Comprehensive (hospital and medical) Individual .................... 2. Comprehensive (hospital and medical) Group .......................... 23. Medicare Supplement ................................................................ 34. Dental Only ................................................................................ 45. Vision Only ................................................................................ 56. Federal Employees Health Benefits Plan .................................. 67. Title XVIII – Medicare .............................................................. 78. Title XIX – Medicaid ................................................................. 9. Credit A&H ................................................................................ 10. Disability Income ....................................................................... 11. Long-Term Care .........................................................................812. Other health ................................................................................913. Health subtotal (Lines 1 to 812) ................................................1014. Health care receivables (a) .........................................................1115. Other non-health ........................................................................1216. Medical incentive pools and bonus amounts .............................1317. Totals (Lines 913-1014+1115+1216)

................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................

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(a) Excludes $……….. loans or advances to providers not yet expensed.

Attachment J


UNDERWRITING AND INVESTMENT EXHIBIT PART 2D – AGGREGATE RESERVE FOR ACCIDENT AND HEALTH CONTRACTS ONLY

1 Comprehensive

(Hospital &Medical)2 34 45 56 67 78 89 10 11 12 913

2 3

Total

Comprehensive (Hospital &Medical) Individual Group


Federal Employees




Disability Income

Long-Term Care Other

1. Unearned premium reserves ......................................................................... 2. Additional policy reserves (a)....................................................................... 3. Reserve for future contingent benefits .......................................................... 4. Reserve for rate credits or experience rating refunds (including

$............ for investment income) .................................................................. 5. Aggregate write-ins for other policy reserves............................................... 6. Totals (gross) ................................................................................................ 7. Reinsurance ceded ........................................................................................ 8. Totals (Net) (Page 3, Line 4) ........................................................................

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9. Present value of amounts not yet due on claims ........................................... 10. Reserve for future contingent benefits .......................................................... 11. Aggregate write-ins for other claim reserves ................................................ 12. Totals (gross) ................................................................................................ 13. Reinsurance ceded ........................................................................................ 14. Totals (Net) (Page 3, Line 7)

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DETAILS OF WRITE-INS 0501. ......................................................................................................................0502. ......................................................................................................................0503. ......................................................................................................................0598. Summary of remaining write-ins for Line 5 from overflow page.................0599. Totals (Lines 0501 through 0503 plus 0598) (Line 5 above)

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1101. ......................................................................................................................1102. ......................................................................................................................1103. ......................................................................................................................1198. Summary of remaining write-ins for Line 11 from

overflow page ...............................................................................................1199. Totals (Lines 1101 through 1103 plus 1198) (Line 11 above)

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(a) Includes $................. premium deficiency reserve.

Attachment J


Affix Bar Code Above

EXHIBIT OF PREMIUMS, ENROLLMENT AND UTILIZATION (a) REPORT FOR: 1. CORPORATION _________________________________________________ 2. ___________________________________________________________________________

(LOCATION)

NAIC Group Code ____________ BUSINESS IN THE STATE OF _____________________________________________ DURING THE YEAR NAIC Company Code ________________


4 5 6 7 8 9 10 11 12 13 1014

2 3


Supplement Dental Vision

Only Vision Dental

Only

Federal Employees




Disability Income


Other Non-Health

Total Members at end of: 1. Prior Year ............................................................. 2. First Quarter ......................................................... 3. Second Quarter ..................................................... 4. Third Quarter ........................................................ 5. Current Year

............................................................................................................

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6. Current Year Member Months Total Member Ambulatory Encounters for Year:

7. Physician .............................................................. 8. Non-Physician ......................................................

........................... ........................... ........................... .......................... .......................... ....................... ...........................

........................ ........................ .......................... .......................... .......................... .......................... ..........................

9. Total 10. Hospital Patient Days Incurred 11. Number of Inpatient Admissions 12. Health Premiums Written (b) ............................... ........................... ........................... ........................... .......................... .......................... ....................... ........................... ........................ ........................ .......................... .......................... .......................... .......................... .......................... 13. Life Premiums Direct ........................................... ........................... ........................... ........................... .......................... .......................... ....................... ........................... ........................ ........................ .......................... .......................... .......................... .......................... .......................... 14. Property/Casualty Premiums Written ................... ........................... ........................... ........................... .......................... .......................... ....................... ........................... ........................ ........................ .......................... .......................... .......................... .......................... .......................... 15. Health Premiums Earned ...................................... ........................... ........................... ........................... .......................... .......................... ....................... ........................... ........................ ........................ .......................... .......................... .......................... .......................... .......................... 16. Property/Casualty Premiums Earned 17. Amount Paid for Provision of Health Care

Services .................................................................. ...........................

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.......................

...........................

........................

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18. Amount Incurred for Provision of Health Care Services

(a) For health business: number of persons insured under PPO managed care products____ and number of persons insured under indemnity only products____. (b) For health premiums written: amount of Medicare Title XVIII exempt from state taxes or fees $……………

Attachment J


QUARTERLY STATEMENT BLANK – HEALTH

EXHIBIT OF PREMIUMS, ENROLLMENT AND UTILIZATION

1 Comprehensive (Hospital & Medical) 4 5 6 7 8 9 10 11 12 13 1014 2 3


Supplement Dental Vision

Only Vision Dental

Only

Federal Employees




Disability Income

Long-Term Care Other Health Other Non-Health

Total Members at end of: 1. Prior Year ...................................................................... 2. First Quarter .................................................................. 3. Second Quarter .............................................................. 4. Third Quarter ................................................................. 5. Current Year

................... ................... ................... ...................

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6. Current Year Member Months Total Member Ambulatory Encounters for Period: 7. Physician ....................................................................... 8. Non-Physician ...............................................................

................... ........................ .......................... ........................... .......................... ........................... ...........................

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9. Total 10. Hospital Patient Days Incurred 11. Number of Inpatient Admissions 12. Health Premiums Written (a) ......................................... ................... ........................ .......................... ........................... .......................... ........................... ........................... ........................... ........................... .......................... ........................... .......................... ........................... ........................... 13. Life Premiums Direct .................................................... ................... ........................ .......................... ........................... .......................... ........................... ........................... ........................... ........................... .......................... ........................... .......................... ........................... ........................... 14. Property/Casualty Premiums Written ............................ ................... ........................ .......................... ........................... .......................... ........................... ........................... ........................... ........................... .......................... ........................... .......................... ........................... ........................... 15. Health Premiums Earned ............................................... ................... ........................ .......................... ........................... .......................... ........................... ........................... ........................... ........................... .......................... ........................... .......................... ........................... ........................... 16. Property/Casualty Premiums Earned ................... ........................ .......................... ........................... .......................... ........................... ........................... ........................... ........................... .......................... ........................... .......................... ........................... ........................... 17. Amount Paid for Provision of Health Care Services ..... ................... ........................ .......................... ........................... .......................... ........................... ........................... ........................... ........................... .......................... ........................... .......................... ........................... ........................... 18. Amount Incurred for Provision of Health Care

Services

(a) For health premiums written: amount of Medicare Title XVIII exempt from state taxes or fees $………..

Attachment J


UNDERWRITING AND INVESTMENT EXHIBIT ANALYSIS OF CLAIMS UNPAID-PRIOR YEAR-NET OF REINSURANCE

Claims Paid Year

to Date

Liability End of

Current Quarter

5 6

Line of

Business

1 On

Claims Incurred Prior to January 1 of Current Year

2 On


Year

3 On

Claims Unpaid Dec. 31 of Prior Year

4 On


Year

Claims Incurred

in Prior Years

(Columns 1 + 3)

Estimated Claim Reserve and

Claim Liability Dec. 31 of Prior Year

1. Comprehensive (hospital and medical) Individual .................. 2. Comprehensive (hospital and medical) Group ........................ 23. Medicare Supplement .............................................................. 34. Dental only ............................................................................... 45. Vision only ............................................................................... 56. Federal Employees Health Benefits Plan ................................ 67. Title XVIII – Medicare ............................................................ 78. Title XIX – Medicaid ............................................................... 9. Credit A&H .............................................................................. 10. Disability Income ..................................................................... 11. Long-Term Care ....................................................................... 812. Other health .............................................................................. 913. Health subtotal (Lines 1 to 812) .............................................. 1014. Health care receivables (a) ....................................................... 1115. Other non-health ...................................................................... 1216. Medical incentive pools and bonus amounts ........................... 1317. Totals (Lines 913-1014+1115+1216)

................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................

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(a) Excludes $………. loans or advances to providers not yet expensed.


Attachment K




DATE: 10/22/2021

CONTACT PERSON:

TELEPHONE:


NAME: Jacob W. Garn

TITLE: Chair, Blanks Working Group

AFFILIATION:

ADDRESS:







[ X ] Life, Accident & Health/Fraternal [ ] Separate Accounts [ ] Title [ ] Property/Casualty [ ] Protected Cell [ ] Other _______________________ [ ] Health [ ] Health (Life Supplement)


IDENTIFICATION OF ITEM(S) TO CHANGE Starting at Line 72 of the Life/Fraternal Five-Year Historical add or delete lines that don’t pull in the specific lines of business reported on the Life/Fraternal Analysis of Operations by Lines of Business detail pages for life (individual and group, annuities (individual and group and A&H for Line 33 of those pages.

REASON, JUSTIFICATION FOR AND/OR BENEFIT OF CHANGE** The purpose of this proposal is to bring back the line of business detail reporting of Net Gains from Operations After Dividends to Policyholders/Refunds to Members and Federal Income Taxes by Lines of Business as was done before the Life/Fraternal Analysis of Operations by Lines of Business page was expanded for the new lines of business categories.


Attachment K


ANNUAL STATEMENT INSTRUCTIONS – LIFE/FRATERNAL

FIVE-YEAR HISTORICAL DATA


Net Gains From Operations After Dividends to Policyholders/Refunds to Members and Federal Income Taxes by Lines of Business Line 72 – Individual Industrial Life

All years ............................... Page 6.1, Line 33, Column 2 Line 73 – Individual Whole Life

All years ............................... Page 6.1, Line 33, Column 3 Line 74 – Individual Term Life

All years ............................... Page 6.1, Line 33, Column 4 Line 75 – Individual Indexed Life

All years ............................... Page 6.1, Line 33, Column 5 Line 76 – Individual Universal Life

All years ............................... Page 6.1, Line 33, Column 6 Line 77 – Individual Universal Life With Secondary Guarantees

All years ............................... Page 6.1, Line 33, Column 7 Line 78 – Individual Variable Life

All years ............................... Page 6.1, Line 33, Column 8 Line 79 – Individual Variable Universal Life

All years ............................... Page 6.1, Line 33, Column 9 Line 80 – Individual Credit Life

All years ............................... Page 6.1, Line 33, Column 10 Line 81 – Individual Other Life

All years ............................... Page 6.1, Line 33, Column 11 Line 82 – Individual YRT Mortality Risk Only

All years ............................... Page 6.1, Line 33, Column 12

Attachment K


Line 83 – Group Whole Life

All years ............................... Page 6.2, Line 33, Column 2 Line 84 – Group Term Life

All years ............................... Page 6.1, Line 33, Column 3 Line 85 – Group Universal Life

All years ............................... Page 6.2, Line 33, Column 4 Line 86 – Group Variable Life

All years ............................... Page 6.2, Line 33, Column 5 Line 87 – Group Variable Universal Life

All years ............................... Page 6.1, Line 33, Column 6 Line 88 – Group Credit Life

All years ............................... Page 6.2, Line 33, Column 7 Line 89 – Group Other Life

All years ............................... Page 6.2, Line 33, Column 8 Line 90 – Group YRT Mortality Risk Only

All years ............................... Page 6.2, Line 33, Column 9 Line 73 – Ordinary – Life

All years ............................... Page 6.1, Line 33, Column 1 less Columns 2, 10 and 12 Line 7491 – Ordinary – Individual Deferred Fixed Annuities

All years ............................... Page 6.3, Line 33, Column 42 Line 92 – Individual Deferred Indexed Annuities

All years ............................... Page 6.3, Line 33, Column 3 Line 93 – Individual Deferred Variable Annuities With Guarantees

All years ............................... Page 6.3, Line 33, Column 4 Line 94 – Individual Deferred Variable Annuities Without Guarantees

All years ............................... Page 6.3, Line 33, Column 5 Line 95 – Individual Contingent Payout (Immediate and Annuitization)


Attachment K


Line 96 – Individual Other Annuities

All years ............................... Page 6.3, Line 33, Column 7 Line 75 – Ordinary – Supplementary Contracts

All years ............................... No longer a separate column on the Analysis of Operations by Lines of Business pages. The amounts are included in the individual and group annuities amounts on Lines 74 and 78.

Line 76 – Credit Life

All years ............................... Line 33, Page 6.1, Column 10 plus Page 6.2, Column 7 Line 77 – Group Life

All years ............................... Page 6.2, Line 33, Column 1 less Columns 7 and 9 Line 7897 – Group Deferred Fixed Annuities

All years ............................... Page 6.4, Line 33, Column 52 Line 98 – Group Deferred Indexed Annuities

All years ............................... Page 6.4, Line 33, Column 3 Line 99 – Group Deferred Variable Annuities With Guarantees

All years ............................... Page 6.4, Line 33, Column 4 Line 100 – Group Deferred Variable Annuities Without Guarantees

All years ............................... Page 6.4, Line 33, Column 5 Line 101 – Group Contingent Payout (Immediate and Annuitization)

All years ............................... Page 6.4, Line 33, Column 6 Line 102 – Group Other Annuities

All years ............................... Page 6.4, Line 33, Column 7 Line 103 – A & H – Comprehensive Group

All years ............................... Page 6.5, Line 33, Column 2 Line 79104 – A & H – Comprehensive Group


Attachment K


Line 105 – A & H – Medicate Supplement

All years ............................... Page 6.5, Line 33, Column 4 Line 106 – A & H – Vision Only

All years ............................... Page 6.5, Line 33, Column 5 Line 107 – A & H – Dental Only

All years ............................... Page 6.5, Line 33, Column 6 Line 108 – A & H – Federal Employees Health Benefits Plan

All years ............................... Page 6.5, Line 33, Column 7 Line 109 – A & H – Title XVII Medicare

All years ............................... Page 6.5, Line 33, Column 8 Line 110 – A & H – Title XIX Medicaid

All years ............................... Page 6.5, Line 33, Column 9 Line 80111 – A&H – Credit

All years ............................... Page 6.5, Line 33, Column 10 Line 112 – A & H – Disability Income

All years ............................... Page 6.5, Line 33, Column 11 Line 113 – A & H – Long-Term Care

All years ............................... Page 6.5, Line 33, Column 12 Line 81114 – A&H – Other Health

All years ............................... Page 6.5, Line 33, Column 13 less Columns 3 and 10 Line 82115 – Aggregate of All Other Lines of Business

All years ............................... Page 6, Line 33, Column 8 Line 83116 – Fraternal

All years ............................... Page 6, Line 33, Column 7

Attachment K


ANNUAL STATEMENT BLANKS – LIFE/FRATERNAL

FIVE–YEAR HISTORICAL DATA Show amounts in whole dollars only, no cents; show percentages to one decimal place, i.e., 17.6

$000 omitted for amounts of life insurance

1 2 3 4 5 2019 2020 2021 2022 2023


Net Gains From Operations After Dividends to Policyholders/Members' Refunds and Federal Income Taxes by Lines of Business (Page 6.x, Line 33) 72. Individual Iindustrial life (Page 6.1, Col. 2).................................................................... ......................... ............................ ............................ ............................ ............................. 73. Individual whole life (Page 6.1, Col. 3) .......................................................................... ......................... ............................ ............................ ............................ ............................. 74. Individual term life (Page 6.1, Col. 4) ............................................................................. ......................... ............................ ............................ ............................ ............................. 75. Individual indexed life (Page 6.1, Col. 5) ....................................................................... ......................... ............................ ............................ ............................ ............................. 76. Individual universal life (Page 6.1, Col. 6) ..................................................................... ......................... ............................ ............................ ............................ ............................. 77. Individual universal life with secondary guarantees (Page 6.1, Col. 7) .......................... ......................... ............................ ............................ ............................ ............................. 78. Individual variable life (Page 6.1, Col. 8) ....................................................................... ......................... ............................ ............................ ............................ ............................. 79. Individual variable universal life (Page 6.1, Col. 9) ....................................................... ......................... ............................ ............................ ............................ ............................. 80. Individual credit life (Page 6.1, Col. 10) ......................................................................... ......................... ............................ ............................ ............................ ............................. 81. Individual other life (Page 6.1, Col. 11) .......................................................................... ......................... ............................ ............................ ............................ ............................. 82. Individual YRT mortality risk only (Page 6.1, Col. 12) ................................................. ......................... ............................ ............................ ............................ ............................. 83. Group whole life (Page 6.2, Col. 2) ................................................................................ ......................... ............................ ............................ ............................ ............................. 84. Group term life (Page 6.2, Col. 3) ................................................................................... ......................... ............................ ............................ ............................ ............................. 85. Group universal life (Page 6.2, Col.4) ............................................................................ ......................... ............................ ............................ ............................ ............................. 86. Group variable life (Page 6.2, Col. 5) ............................................................................. ......................... ............................ ............................ ............................ ............................. 87. Group variable universal life (Page 6.2, Col. 6) .............................................................. ......................... ............................ ............................ ............................ ............................. 88. Group credit life (Page 6.2, Col. 7) ................................................................................. ......................... ............................ ............................ ............................ ............................. 89. Group other life (Page 6.2, Col. 8) .................................................................................. ......................... ............................ ............................ ............................ ............................. 90. Group YRT mortality risk only (Page 6.2, Col. 9) .......................................................... ......................... ............................ ............................ ............................ ............................. 73. Ordinary-life (Page 6.1, Col. 1 less Cols. 2, 10 and 12).................................................. ......................... ............................ ............................ ............................ ............................. 7491. Ordinary-iIndividual deferred fixed annuities (Page 6.3, Col. 42) ................................. ......................... ............................ ............................ ............................ ............................. 92. Individual deferred indexed annuities (Page 6.3, Col. 3) ................................................ ......................... ............................ ............................ ............................ ............................. 93. Individual deferred variable annuities with guarantees (Page 6.3, Col. 4) ...................... ......................... ............................ ............................ ............................ ............................. 94. Individual deferred variable annuities without guarantees (Page 6.3, Col. 5) ................. ......................... ............................ ............................ ............................ ............................. 95. Individual life contingent payout (Immediate and annuitization (Page 6.3, Col. 6) ........ ......................... ............................ ............................ ............................ ............................. 96. Individual other annuities (Page 6.3, Col. 7) ................................................................... ......................... ............................ ............................ ............................ ............................. 75. Ordinary-supplementary contracts .................................................................................. XXX XXX XXX XXX XXX 76. Credit life (Page 6.1, Col. 10 plus Page 6.2, Col. 7) ....................................................... ......................... ............................ ............................ ............................ ............................. 77. Group life (Page 6.2, Col.1 less Cols. 7 and 9) ............................................................... ......................... ............................ ............................ ............................ ............................. 7897. Group deferred fixed annuities (Page 6.4, Col. 52)......................................................... ......................... ............................ ............................ ............................ ............................. 98. Group deferred indexed annuities (Page 6.4, Col. 3) ...................................................... ......................... ............................ ............................ ............................ ............................. 99. Group deferred variable annuities with guarantees (Page 6.4, Col. 4) ............................ ......................... ............................ ............................ ............................ ............................. 100. Group deferred variable annuities without guarantees (Page 6.4, Col. 5)....................... ......................... ............................ ............................ ............................ ............................. 101. Group life contingent payout (Immediate and annuitization (Page 6.4, Col. 6) ............. ......................... ............................ ............................ ............................ ............................. 102. Group other annuities (Page 6.3, Col. 7) ......................................................................... ......................... ............................ ............................ ............................ ............................. 103. A & H-comprehensive individual (Page 6.5, Col. 2) ...................................................... ......................... ............................ ............................ ............................ ............................. 79104. A & H-comprehensive group (Page 6.5, Col. 3) ............................................................. ......................... ............................ ............................ ............................ ............................. 105. A & H-Medicare supplement (Page 6.5, Col. 4) ............................................................. ......................... ............................ ............................ ............................ ............................. 106. A & H-vision only (Page 6.5, Col. 5) .............................................................................. ......................... ............................ ............................ ............................ ............................. 107. A & H-dental only (Page 6.5, Col. 6) .............................................................................. ......................... ............................ ............................ ............................ ............................. 108. A & H-federal employees health benefits plan (Page 6.5, Col. 7) .................................. ......................... ............................ ............................ ............................ ............................. 109. A & H-Title XVIII Medicare (Page 6.5, Col. 8) ............................................................. ......................... ............................ ............................ ............................ ............................. 110. A & H-Title XIX Medicaid (Page 6.5, Col. 9) ................................................................ ......................... ............................ ............................ ............................ ............................. 80111. A & H-credit (Page 6.5, Col. 10) .................................................................................... ......................... ............................ ............................ ............................ ............................. 112. A & H-disability income (Page 6.5, Col. 11) .................................................................. ......................... ............................ ............................ ............................ ............................. 113. A & H-long-term care (Page 6.5, Col. 12) ...................................................................... ......................... ............................ ............................ ............................ ............................. 81114. A & H-other (Page 6.5, Col. 1 less Cols. 3 and 1013) .................................................... ......................... ............................ ............................ ............................ ............................. 82115. Aggregate of all other lines of business (Page 6, Col. 8) ................................................ ......................... ............................ ............................ ............................ ............................. 83116. Fraternal (Page 6, Col. 7) ................................................................................................

84117. Total (Page 6, Col. 1)


W:\QA\BlanksProposals\Proposals In Progress\Life Fraternal 5 Year Historical\2021-20BWG.doc

Attachment L




DATE: 10/25/2021

CONTACT PERSON:

TELEPHONE:



TITLE: Chair SAPWG



Columbus, OH 43215






[ X ] ANNUAL STATEMENT [ X ] INSTRUCTIONS [ ] CROSSCHECKS [ X ] QUARTERLY STATEMENT [ ] BLANK

[ X ] Life, Accident & Health/Fraternal [ ] Separate Accounts [ X ] Title [ X ] Property/Casualty [ ] Protected Cell [ ] Other _______________________ [ X ] Health [ ] Health (Life Supplement)


IDENTIFICATION OF ITEM(S) TO CHANGE Add instruction to the Investment Schedules General Instructions to exclude non-rated residual tranches or interests from being reported as bonds on Schedule D, Part 1 and add lines to Schedule BA for the reporting of those investments.

REASON, JUSTIFICATION FOR AND/OR BENEFIT OF CHANGE** The purpose of this proposal is to reflect changes being adopted by the Statutory Accounting Principles (E) Working Group SSAP No. 43R – Loan-Backed and Structured Securities (Ref #2021-15). The proposal excludes non-rated residual tranches or interests from being reported as bonds on Schedule D, Part 1 and requires them to be reported on Schedule BA


Attachment L


ANNUAL STATEMENT INSTRUCTIONS – LIFE/FRATERNAL, HEALTH, PROPERTY AND TITLE

SCHEDULE BA – PARTS 1, 2 AND 3

OTHER LONG-TERM INVESTED ASSETS – GENERAL INSTRUCTIONS


Group or Category Line Number Oil and Gas Production

Unaffiliated ........................................................................................................................................................ 0199999 Affiliated ........................................................................................................................................................... 0299999


Non-rated Residual Tranches or Interests

Fixed Income Instruments

Unaffiliated ........................................................................................................................... 4699999

Affiliated ............................................................................................................................... 4799999

Common Stock

Unaffiliated ........................................................................................................................... 4899999 Affiliated ............................................................................................................................... 4999999

Real Estate


Mortgage Loans


Other


Any Other Class of Assets

Unaffiliated .......................................................................................................................................... 46999995699999 Affiliated ............................................................................................................................................. 47999995799999

Subtotals


TOTALS ............................................................................................................................................................ 50999995999999 The following listing is intended to give examples of investments to be included in each category; however, the list should not be considered all inclusive, and it should not be implied that any invested asset currently being reported in Schedules A, B or D is to be reclassified to Schedule BA:

Attachment L


Oil and Gas Production

Include: Offshore oil and gas leases.



Include: Non-rated residual tranches or interests captures securitization tranches, beneficial interests, interests of structured finance investments, as well as other structures captured in scope of SSAP No. 43R – Loan-Backed and Structured Securities, that reflect loss layers without contractual interest or principal payments. Payments to holders of these investments occur after contractual interest and principal payments have been made to other tranches or interests and are based on the remaining available funds.See SSAP No. 43R for accounting guidance.


Include: Investments that do not fit into one of the other categories. An example of items that may be included are reverse mortgages.

All structured settlement income streams acquired as investments where the reporting entity acquires the legal right to receive payments. (Valuation and admittance provisions are detailed in SSAP No. 21R—Other Admitted Assets.)

Attachment L


QUARTERLY STATEMENT INSTRUCTIONS – LIFE/FRATERNAL, HEALTH, PROPERTY AND TITLE

SCHEDULE BA PARTS 2 AND 3

OTHER LONG-TERM INVESTED ASSETS ACQUIRED AND DISPOSED OF


Group or Category Line Number Oil and Gas Production

Unaffiliated ........................................................................................................................................................ 0199999 Affiliated ........................................................................................................................................................... 0299999



Fixed Income Instruments

Unaffiliated ........................................................................................................................... 4699999

Affiliated ............................................................................................................................... 4799999

Common Stock


Real Estate


Mortgage Loans


Other




Subtotals


TOTALS ............................................................................................................................................................ 50999995999999 The following listing is intended to give examples of investments to be included in each category; however, the list should not be considered all-inclusive and it should not be implied that any invested asset currently being reported in Schedules A, B or D is to be reclassified to Schedule BA.

Attachment L


Oil and Gas Production

Include: Offshore oil and gas leases.



Include: Non-rated residual tranches or interests captures securitization tranches, beneficial interests, interests of structured finance investments, as well as other structures captured in scope of SSAP No. 43R – Loan-Backed and Structured Securities, that reflect loss layers without contractual interest or principal payments. Payments to holders of these investments occur after contractual interest and principal payments have been made to other tranches or interests and are based on the remaining available funds.See SSAP No. 43R for accounting guidance.


Include: Investments that do not fit into one of the other categories. An example of items that may be included are reverse mortgages.

All structured settlement income streams acquired as investments where the reporting entity acquires the legal right to receive payments. (Valuation and admittance provisions are detailed in SSAP No. 21R—Other Admitted Assets.)

Attachment L


ANNUAL AND QUARTERLY STATEMENT INSTRUCTIONS – LIFE/FRATERNAL, HEALTH, PROPERTY AND TITLE

INVESTMENT SCHEDULES GENERAL INSTRUCTIONS (Applies to all investment schedules)


The following is the description of the General and Specific Classifications used for reporting the detail lines for bonds and stocks. General Classifications Bonds Only: Exclude non-rated residual tranches or interests captured in scope of SSAP No. 43R – Loan-Backed and Structured Securities. See SSAP No. 43R for accounting guidance. These securities should be reported on Schedule BA. Refer to SSAP No. 26R—Bonds, SSAP No. 43R—Loan-Backed and Structured Securities and SSAP No. 97—Investments in Subsidiary, Controlled and Affiliated Entities for additional guidance.

U.S. Government:

U.S. Government shall be defined as U.S. Government Obligations as defined per the Purposes and Procedures Manual of the NAIC Investment Analysis Office.



Attachment M


Blanks (E) Working Group Editorial Revisions to the Blanks and Instructions (presented at the November 16, 2021, Meeting) Statement Type: H = Health; L/F = Life/Fraternal Combined; P/C = Property/Casualty; SA = Separate Accounts; T = Title

Effective Statement Type

Filing Type

2021 Annual

Life, Health & Annuity Guaranty Association Assessable Premium Exhibit Part 2

CHANGE TO BLANK Block column 4, line 19.8 for entry per information from sponsor of proposal 2020-31BWG.

L/F, H, P Annual

2021 Annual

Schedule DB, Part A, Section 2

CHANGE TO BLANK Add “Undiscounted” to columns 13 and 14 descriptions. From 2018-12BWG proposal and missed going forward.

L/F, H, P, T, SA

Annual

2021 Annual

Schedule D, Part 6, Section 1

CHANGE TO BLANK Change column 7 – Book Adjusted Carrying Value to allow a total. It was moved from column 9, which included a total.

L/F, H, P, T, SA

Annual

2022 Annual

Notes to Financial Statements

CHANGE TO INSTRUCTION Add formulas to the illustration for Note 5A(7) to clarify calculation of balance.

A. Mortgage Loans, including Mezzanine Real Estate Loans (7) Allowance for Credit Losses:

a. Balance at beginning of period

b. Additions charged to operations

c. Direct write-downs charged against the allowances

d. Recoveries of amounts previously charged off

e. Balance at end of period (a+b-c-d)

L/F, H, P, T Annual

Attachment M



Filing Type

2022 Annual


CHANGE TO INSTRUCTION

Add formulas to the illustration for Note 5D(2) to clarify calculation of totals.

D. Loan-Backed Securities

(2)

OTTI recognized 1st Quarter a. Intent to sell b. Inability or lack of intent to retain the investment in the security

for a period of time sufficient to recover the amortized cost basis c. Total 1st Quarter (a+b) OTTI recognized 2nd Quarter d. Intent to sell e. Inability or lack of intent to retain the investment in the security

for a period of time sufficient to recover the amortized cost basis f. Total 2nd Quarter (d+e) OTTI recognized 3rd Quarter g. Intent to sell h. Inability or lack of intent to retain the investment in the security

for a period of time sufficient to recover the amortized cost basis i. Total 3rd Quarter (g+h) OTTI recognized 4th Quarter j. Intent to sell k. Inability or lack of intent to retain the investment in the security

for a period of time sufficient to recover the amortized cost basis l. Total 4th Quarter (j+k) m. Annual Aggregate Total (c+f+i+l)

L/F, H, P, T Annual

Attachment M



Filing Type

2022 Annual


CHANGE TO INSTRUCTION Add formulas to the illustration for Note 5E(3) and 5E(5) to clarify calculation of subtotals and totals.

E. Dollar Repurchase Agreements and/or Securities Lending Transactions (3) Collateral Received

a. Aggregate Amount Collateral Received

1. Securities Lending

(a) Open (b) 30 Days or Less (c) 31 to 60 Days (d) 61 to 90 Days (e) Greater Than 90 Days (f) Sub-Total (a+b+c+d+e)

(g) Securities Received (h) Total Collateral Received (f+g)

2. Dollar Repurchase Agreement

(a) Open (b) 30 Days or Less (c) 31 to 60 Days (d) 61 to 90 Days (e) Greater Than 90 Days (f) Sub-Total (a+b+c+d+e)

(g) Securities Received (h) Total Collateral Received (f+g)

(5) Collateral Reinvestment

a. Aggregate Amount Collateral Reinvested

1. Securities Lending

(a) Open (b) 30 Days or Less (c) 31 to 60 Days

L/F, H, P, T Annual

Attachment M



Filing Type

(d) 61 to 90 Days (e) 91 to 120 Days (f) 121 to 180 Days (g) 181 to 365 Days (h) 1 to 2 Years (i) 2 to 3 Year (j) Greater Than 3 Years (k) Sub-Total (Sum of a through j)

(l) Securities Received (m) Total Collateral Reinvested (k+l)

2. Dollar Repurchase Agreement

(a) Open (b) 30 Days or Less (c) 31 to 60 Days (d) 61 to 90 Days (e) 91 to 120 Days (f) 121 to 180 Days (g) 181 to 365 Days (h) 1 to 2 Years (i) 2 to 3 Year (j) Greater Than 3 Years (k) Sub-Total (Sum of a through j)

(l) Securities Received (m) Total Collateral Reinvested (k+l)

Attachment M



Filing Type

2022 Annual


CHANGE TO INSTRUCTION Add formula to the illustration for Note 5L(1) to clarify calculation of total.

L. Restricted Assets (1) Restricted Assets (Including Pledged)

Restricted Asset Category

a. Subject to contractual obligation for which liability is not shown

b. Collateral held under security lending agreements

c. Subject to repurchase agreements

d. Subject to reverse repurchase agreements

e. Subject to dollar repurchase agreements

f. Subject to dollar reverse repurchase agreements

g. Placed under option contracts

h. Letter stock or securities restricted as to sale – excluding FHLB capital stock

i. FHLB capital stock

j. On deposit with states

k. On deposit with other regulatory bodies

l. Pledged as collateral to FHLB (including assets backing funding agreements)

m. Pledged as collateral not captured in other categories

n. Other restricted assets

o. Total Restricted Assets (Sum of a through n)

(a) Subset of Column 1 (b) Subset of Column 3

L/F, H, P, T Annual

Attachment M



Filing Type

2022 Annual


CHANGE TO INSTRUCTION Add formulas to the illustration for Note 5M(1) and 5M(2) to clarify calculation of totals.

M. Working Capital Finance Investments (1) Aggregate Working Capital Finance Investments (WCFI) Book/Adjusted

Carrying Value by NAIC Designation:

a. WCFI Designation 1

b. WCFI Designation 2

c. WCFI Designation 3

d. WCFI Designation 4

e. WCFI Designation 5

f. WCFI Designation 6

g. Total (a+b+c+d+e+f) (2) Aggregate Maturity Distribution on the Underlying Working Capital

Finance Programs:

a. Up to 180 Days

b. 181 Days to 365 Days

c. Total (a+b)

L/F, H, P, T Annual

Attachment M



Filing Type

2022 Annual



Add formula to the illustration for Note 8A(8) to clarify calculation of total.

A. Derivatives under SSAP No. 86—Derivatives

(8)

a.

Fiscal Year 1. 2022 2. 2023 3. 2024 4. 2025 5. Thereafter 6. Total Future Settled Premiums (Sum of 1 through 5)

L/F, H, P, T Annual

2022 Annual



Add formula to the illustration for Note 8B(2) to clarify calculation of total.

B. Derivatives under SSAP No. 108—Derivative Hedging Variable Annuity Guarantees

(2) Recognition of gains/losses and deferred assets and liabilities

a. Scheduled Amortization

Amortization Year 1. 2022 2. 2023 3. 2024 4. 2025 5. 2026 6. 2027 7. 2028 8. 2029 9. 2030 10. 2031 11. Total (Sum of 1 through 10)

L/F, H, P, T Annual

Attachment M



Filing Type

2022 Annual


CHANGE TO INSTRUCTION Add formula to the illustration for Note 14A(3)c to clarify calculation of total.

A. Contingent Commitments

(3)

a. Aggregate Maximum Potential of Future Payments of All Guarantees (undiscounted) the guarantor could be required to make under guarantees. (Should equal total of Column 4 for (2) above.)

b. Current Liability Recognized in F/S:

1. Noncontingent Liabilities 2. Contingent Liabilities

c. Ultimate Financial Statement Impact if action under the guarantee is required.

1. Investments in SCA 2. Joint Venture 3. Dividends to Stockholders (capital contribution) 4. Expense 5. Other 6. Total (1+2+3+4+5) (Should equal (3)a.)

L/F, H, P, T Annual

2022 Annual


CHANGE TO INSTRUCTION Add formulas to the illustration for Note 16(1) to clarify calculation of total. (1) The table below summarizes the face amount of the Company’s financial

instruments with off-balance-sheet risk.

a. Swaps

b. Futures

c. Options

d. Total (a+b+c)

L/F, H, P, T Annual

Attachment M



Filing Type

2022 Annual



Add formulas to the illustration for Note 21F(2), 21F(3) and 21F(4)to clarify calculation of totals.

F. Subprime-Mortgage-Related Risk Exposure

(2) Direct exposure through investments in subprime mortgage loans.

a. Mortgages in the process of foreclosure

b. Mortgages in good standing

c. Mortgages with restructured terms

d. Total (a+b+c)

(3) Direct exposure through other investments.

a. Residential mortgage-backed securities

b. Commercial mortgage-backed securities

c. Collateralized debt obligations

d. Structured securities

e. Equity investment in SCAs *

f. Other assets

g. Total (a+b+c+d+e+f)

* ABC Company’s subsidiary XYZ Company has investments in subprime mortgages. These investments comprise _____% of the companies invested assets.

(4) Underwriting exposure to subprime mortgage risk through Mortgage Guaranty or Financial Guaranty insurance coverage.

a. Mortgage guaranty coverage

b. Financial guaranty coverage

c. Other lines (specify):

...................................................

...................................................

...................................................

d. Total (Sum of a through c)

L/F, H, P, T Annual

Attachment M



Filing Type

2022 Annual


CHANGE TO INSTRUCTION Add formulas to the illustration for Note 18A and 18B to clarify calculation of totals.

A. ASO Plans

a. Net reimbursement for administrative expenses (including administrative fees) in excess of actual expenses

b. Total net other income or expenses (including interest paid to or received from plans)

c. Net gain or (loss) from operations (a+b)

d. Total claim payment volume

B. ASC Plans

a. Gross reimbursement for medical cost incurred

b. Gross administrative fees accrued

c. Other income or expenses (including interest paid to or received from plans)

d. Gross expenses incurred (claims and administrative) (a+b+c)

e. Total net gain or loss from operations

L/F, H, P Annual

2022 Annual


CHANGE TO INSTRUCTION Add formula to the illustration for Note 21G(2) to clarify calculation of total.

G. Retained Assets (2)

a. Up to and including 12 months b. 13 to 24 months c. 25 to 36 months d. 37 to 48 months e. 49 to 60 months f. Over 60 months g. Total (a+b+c+d+e+f)

L/F, H Annual

Attachment M



Filing Type

2022 Annual



Add formulas to the illustration for Note 32D to clarify calculation of totals.

D. Life & Accident & Health Annual Statement:

(1) Exhibit 5, Annuities Section, Total (net) (2) Exhibit 5, Supplementary Contracts with Life Contingencies Section, Total

(net) (3) Exhibit 7, Deposit-Type Contracts, Line 14, Column 1 (4) Subtotal (1+2+3)

Separate Accounts Annual Statement:

(5) Exhibit 3, Line 0299999, Column 2 (6) Exhibit 3, Line 0399999, Column 2 (7) Policyholder dividend and coupon accumulations (8) Policyholder premiums (9) Guaranteed interest contracts (10) Other contract deposit funds

(11) Subtotal (5+6+7+8+9+10)

(12) Combined Total (4+11)

L/F Annual

2022 Annual



Add formulas to the illustration for Note 33D to clarify calculation of totals.

D.

Life & Accident & Health Annual Statement:

(1) Exhibit 5, Life Insurance Section, Total (net) (2) Exhibit 5, Accidental Death Benefits Section, Total (net) (3) Exhibit 5, Disability – Active Lives Section, Total (net) (4) Exhibit 5, Disability – Disabled Lives Section, Total (net) (5) Exhibit 5, Miscellaneous Reserves Section, Total (net) (6) Subtotal (1+2+3+4+5)

Separate Accounts Annual Statement:

(7) Exhibit 3, Line 0199999, Column 2 (8) Exhibit 3, Line 0499999, Column 2 (9) Exhibit 3, Line 0599999, Column 2

(10) Subtotal (Lines (7) through (9)) (7+8+9)

(11) Combined Total ((6) and (10)) (6+10)

L/F Annual

Attachment M



Filing Type

2022 Annual



Add formula to the illustration for Note 34A to clarify calculation of total.

A. Deferred and uncollected life insurance premiums and annuity considerations as of December 31, 20___, were as follows:

Type (1) Industrial (2) Ordinary new business (3) Ordinary renewal (4) Credit Life (5) Group Life (6) Group Annuity (7) Totals (1+2+3+4+5+6)

L/F Annual

2022 Annual



Add formulas to the illustration for Note 35B to clarify calculation of totals.

(1) Premiums, considerations or deposits for year ended 12/31/___ Reserves at 12/31/___

(2) For accounts with assets at:

a. Fair value

b. Amortized cost

c. Total Reserves* (a+b) (3) By withdrawal characteristics:

a. Subject to discretionary withdrawal:

1. With market value adjustment

2. At book value without market value adjustment and with current surrender charge of 5% or more

3. At fair value

4. At book value without market value adjustment and with current surrender charge less than 5%

5. Subtotal (1+2+3+4)

b. Not subject to discretionary withdrawal

c. Total (a+b)

* Line 2(c) should equal Line 3(c).

(4) Reserves for Asset Default Risk in Lieu of AVR

L/F Annual

Attachment M



Filing Type

2022 Annual



Add formulas to the illustration for Note 23C to clarify calculation of totals.

C. Reinsurance Assumed and Ceded

(1) a. Affiliates

b. All Other

c. TOTAL (a+b)

d. Direct Unearned Premium Reserve

Line (c) of Ceded Reinsurance Premium Reserve Column must equal Page 3, Line 9, first inside amount.

(2) The additional or return commission, predicated on loss experience or on any other form of profit sharing arrangements in this annual statement as a result of existing contractual arrangements is accrued as follows:

REINSURANCE

a. Contingent Commission

b. Sliding Scale Adjustments

c. Other Profit Commission Arrangements

d. TOTAL (a+b+c)

P, T Annual

2022 Annual



Add formula to the illustration for Note 14A(3)c to clarify calculation of total.

A. Contingent Commitments

(3)

c. Ultimate Financial Statement Impact if action under the guarantee is required.

1. Investments in SCA 2. Joint Venture 3. Dividends to Stockholders (capital contribution) 4. Expense 5. Other 6. Total (1+2+3+4+5) (Should equal (3)a.)

P Annual

Attachment M



Filing Type

2022 Annual


CHANGE TO INSTRUCTION Add formulas to the illustration for Note 23F(1) to clarify calculation of totals.

F. Retroactive Reinsurance

(1)

a. Reserves Transferred:

1. Initial Reserves

2. Adjustments – Prior Year(s)

3. Adjustments – Current Year

4. Current Total (1+2+3)

b. Consideration Paid or Received:

1. Initial Consideration



4. Current Total (1+2+3)

c. Paid Losses Reimbursed or Recovered:

1. Prior Year(s)

2. Current Year

3. Current Total (1+2)

d. Special Surplus from Retroactive Reinsurance:

1. Initial Surplus Gain or Loss



4. Current Year Restricted Surplus

5. Cumulative Total Transferred to Unassigned Funds (1+2+3+4)

P Annual

Attachment M



Filing Type

2022 Annual


CHANGE TO INSTRUCTION Add formula to the illustration for Note 32A to clarify calculation of total.

A. Tabular Discount

Schedule P Lines of Business

1. Homeowners/Farmowners

2. Private Passenger Auto Liability/Medical

3. Commercial Auto/Truck Liability/Medical

4. Workers’ Compensation

5. Commercial Multiple Peril

6. Medical Professional Liability – occurrence

7. Medical Professional Liability – claims-made

8. Special Liability

9. Other Liability – occurrence

10. Other Liability – claims-made

11. Special Property

12. Auto Physical Damage

13. Fidelity, Surety

14. Other (including Credit, Accident & Health)

15. International

16. Reinsurance Nonproportional Assumed Property

17. Reinsurance Nonproportional Assumed Liability

18. Reinsurance Nonproportional Assumed Financial Lines

19. Products Liability – occurrence

20. Products Liability – claims-made

21. Financial Guaranty/Mortgage Guaranty

22. Warranty

23. Total (Sum of Lines 1 through 22)

* Must exclude medical loss reserves and all loss adjustment expense reserves.

P Annual

Attachment M



Filing Type

2022 Annual


CHANGE TO INSTRUCTION Add formula to the illustration for Note 32B to clarify calculation of total.

B. Nontabular Discount

1. Homeowners/Farm owners

2. Private Passenger Auto Liability/Medical

3. Commercial Auto/Truck Liability/Medical

4. Workers’ Compensation

5. Commercial Multiple Peril

6. Medical Professional Liability – occurrence

7. Medical Professional Liability – claims-made

8. Special Liability

9. Other Liability – occurrence

10. Other Liability – claims-made

11. Special Property

12. Auto Physical Damage

13. Fidelity, Surety

14. Other (including Credit, Accident & Health)

15. International

16. Reinsurance Nonproportional Assumed Property

17. Reinsurance Nonproportional Assumed Liability

18. Reinsurance Nonproportional Assumed Financial Lines

19. Products Liability – occurrence

20. Products Liability – claims-made

21. Financial Guaranty/Mortgage Guaranty

22. Warranty

23. Total (Sum of Lines 1 through 22)

Columns in the table above should include medical loss reserves and all loss adjustment expense reserves, whether reported as tabular or nontabular in Schedule P.

P Annual

Attachment M



Filing Type

2022 Annual


CHANGE TO INSTRUCTION Add formulas to the illustration for Note 33A to clarify calculation of totals.

A. (1) Direct –

a. Beginning reserves:

b. Incurred losses and loss adjustment expense:

c. Calendar year payments for losses and loss adjustment expenses:

d. Ending reserves (a+b-c): (2) Assumed Reinsurance –




d. Ending reserves (a+b-c): (3) Net of Ceded Reinsurance –




d. Ending reserves (a+b-c):

P Annual

Attachment M



Filing Type

2022 Annual


CHANGE TO INSTRUCTION Add formulas to the illustration for Note 33D to clarify calculation of totals.

D. (1) Direct –




d. Ending reserves (a+b-c): (2) Assumed Reinsurance –




d. Ending reserves (a+b-c): (3) Net of Ceded Reinsurance –




d. Ending reserves (a+b-c):

P Annual

Attachment M



Filing Type

2022 Annual


CHANGE TO INSTRUCTION Add formulas to the illustration for Note 36A(1)c and 36A(3)b to clarify calculation of totals.

A.

(1) Financial guarantee insurance contracts where premiums are received as installment payments over the period of the contract, rather than at inception:

c. Roll forward of the expected future premiums (undiscounted), including:

1. Expected future premiums – Beginning of Year

2. Less – Premium payments received for existing installment contracts

3. Add – Expected premium payments for new installment contracts

4. Adjustments to the expected future premium payments

5. Expected future premiums – End of Year (1-2+3+4)

(3) Claim liability:

b. Significant components of the change in the claim liability for the period

Components (1) Accretion of the discount

(2) Changes in timing

(3) New reserves for defaults of insured contracts

(4) Change in deficiency reserves

(5) Change in incurred but not reported claims

(6) Total (1+2+3+4+5)

P Annual

Attachment M



Filing Type

2022 Annual


CHANGE TO INSTRUCTION Add formulas to the illustration for Note 36B to clarify calculation of totals.

B. Schedule of insured financial obligations at the end of the period

1. Number of policies 2. Remaining weighted-average contract

period (in years) Insured contractual payments outstanding:

3a. Principal 3b. Interest

3c. Total (3a+3b) 4. Gross claim liability Less:

5a. Gross potential recoveries 5b. Discount, net

6. Net claim liability (4-5a-5b) 7. Unearned premium revenue 8. Reinsurance recoverables

P Annual

Attachment N

© 20210 National Association of Insurance Commissioners 1 Health

HEALTH ENTITIES

COMPANY NAME: NAIC Company Code:

Contact: Telephone:

REQUIRED FILINGS IN THE STATE OF: Filings Made During the Year 20221

(1)

Checklist

(2)

Line #

(3)

REQUIRED FILINGS FOR THE ABOVE STATE

(4) NUMBER OF COPIES*

(5)

DUE DATE

(6) FORM

SOURCE**

(7) APPLICABLE

NOTES Domestic Foreign State NAIC State

I. NAIC FINANCIAL STATEMENTS 1 Annual Statement (8 ½”X14”) EO 3/1 NAIC 1.1 Printed Investment Schedule detail (Pages E01-

E29) EO xxx 3/1 NAIC 2 Quarterly Financial Statement (8 ½” x 14”)

EO 5/15, 8/15, 11/15 NAIC

II. NAIC SUPPLEMENTS 11 Accident & Health Policy Experience Exhibit EO 4/1 NAIC 12 Actuarial Opinion EO 3/1 Company 13 Life Supplemental Data due March 1 EO 3/1 NAIC 14 Life Supplemental Data due April 1 EO 4/1 NAIC 15 Life Supp Statement non-guaranteed elements –

Exh 5, Int. #3 EO 3/1 Company 16 Life Supp Statement on par/non-par policies – Exh

5 Int. 1&2 EO 3/1 Company 17 Life, Health & Annuity Guaranty Association

Assessable Premium Exhibit, Parts 1 and 2Assessment Base Reconciliation Exhibit

EO xxx 4/1 NAIC 18 Life, Health & Annuity Guaranty Assessment Base

Reconciliation Exhibit Adjustment Form

EO xxx 4/1 NAIC 189 Long-Term Care Experience Reporting Forms EO xxx 4/1 NAIC 201

9 Management Discussion & Analysis

EO 4/1 Company 201 Medicare Part D Coverage Supplement

EO

3/1, 5/15, 8/15, 11/15 NAIC

212 Medicare Supplement Insurance Experience Exhibit EO xxx 3/1 NAIC

223 Risk-Based Capital Report EO 3/1 NAIC 234 Schedule SIS N/A N/A 3/1 NAIC 245 Supplemental Compensation Exhibit N/A N/A 3/1 NAIC 256 Supplemental Health Care Exhibit (Parts 1, 2 and

3) EO 4/1 NAIC 267 Supplemental Health Care Exhibit’s Allocation

Report EO 4/1 NAIC 278 Supplemental Investment Risk Interrogatories EO 4/1 NAIC III. ELECTRONIC FILING

REQUIREMENTS 61 Annual Statement Electronic Filing xxx EO xxx 3/1 NAIC 62 March .PDF Filing xxx EO xxx 3/1 NAIC 63 Risk-Based Capital Electronic Filing xxx EO N/A 3/1 NAIC 64 Risk-Based Capital .PDF Filing xxx EO N/A 3/1 NAIC 65 Supplemental Electronic Filing xxx EO xxx 4/1 NAIC 66 Supplemental .PDF Filing xxx EO xxx 4/1 NAIC 67 Quarterly Statement Electronic Filing

xxx EO xxx 5/15, 8/15, 11/15 NAIC

68 Quarterly .PDF Filing xxx EO xxx

5/15, 8/15, 11/15 NAIC

69 June .PDF Filing xxx EO xxx 6/1 NAIC IV. AUDIT/INTERNAL CONTROL

RELATED REPORTS 81 Accountants Letter of Qualifications EO N/A 6/1 Company 82 Audited Financial Reports EO 6/1 Company 83 Audited Financial Reports Exemption Affidavit N/A N/A Company

Attachment N

©20210 National Association of Insurance Commissioners 2 Health

(1)

Checklist

(2)

Line #

(3)



(5)

DUE DATE

(6) FORM

SOURCE**

(7) APPLICABLE


84 Communication of Internal Control Related Matters Noted in Audit EO N/A 8/1 Company

85 Independent CPA (change) N/A N/A Company 86 Management’s Report of Internal Control Over

Financial Reporting N/A N/A 8/1 Company 87 Notification of Adverse Financial Condition N/A N/A Company 88 Relief from the five-year rotation requirement for

lead audit partner EO 3/1 Company 89 Relief from the one-year cooling off period for

independent CPA EO 3/1 Company 90 Relief from the Requirements for Audit

Committees EO 3/1 Company 91 Request for Exemption to File Management’s

Report of Internal Control Over Financial Reporting N/A N/A Company

V. STATE REQUIRED FILINGS 101 Corporate Governance Annual Disclosure*** 0 Company 102 Filings Checklist (with Column 1 completed) 0 State

103 Form B-Holding Company Registration Statement 0 Company 104 Form F-Enterprise Risk Report **** 0 Company 105 ORSA ***** 0 Company 106 Premium Tax 0 State 107 State Filing Fees 0 State 108 Signed Jurat xxx 0 NAIC 109 Group Capital Calculation 0 110 111 112

*If XXX appears in this column, this state does not require this filing, if hard copy is filed with the state of domicile and if the data is filed electronically with the NAIC. If N/A appears in this column, the filing is required with the domiciliary state. EO (electronic only filing).

**If Form Source is NAIC, the form should be obtained from the appropriate vendor. ***For those states that have adopted the NAIC Corporate Governance Annual Disclosure Model Act, an annual disclosure is required of all insurers or insurance groups by June 1. The Corporate Governance Annual Disclosure is a state filing only and should not be submitted by the company to the NAIC. Note however that this filing is intended to be submitted to the lead state if filed at the insurance group level. For more information on lead states, see the following NAIC URL: http://www.naic.org/public_lead_state_report.htm.

****For those states that have adopted the NAIC updated Holding Company Model Act, a Form F filing is required annually by holding company groups. Consistent with the Form B filing requirements, the Form F is a state filing only and should not be submitted by the company to the NAIC. Note however that this filing is intended to be submitted to the lead state. For more information on lead states, see the following NAIC URL: http://www.naic.org/public_lead_state_report.htm *****For those states that have adopted the NAIC Risk Management and Own Risk and Solvency Assessment Model Act, a summary report is required annually by insurers and insurance groups above a specified premium threshold. The ORSA Summary Report is a state filing only and should not be submitted by the company to the NAIC. Note however that this filing is intended to be submitted to the lead state if filed at the insurance group level. For more information on lead states, see the following NAIC URL: http://www.naic.org/public_lead_state_report.htm

Attachment N


NOTES AND INSTRUCTIONS (A-K APPLY TO ALL FILINGS)

A Required Filings Contact Person:

B Mailing Address:

C Mailing Address for Filing Fees:

D Mailing Address for Premium Tax Payments:

E Delivery Instructions:

F Late Filings:

G Original Signatures:

H Signature/Notarization/Certification:

I Amended Filings:

J Exceptions from normal filings:

K Bar Codes (State or NAIC):

L Signed Jurat:

M NONE Filings:

N Filings new, discontinued or modified materially since last year:

Attachment N


General Instructions For Companies to Use Checklist

Please Note: This state’s instructions for companies to file with the NAIC are included in this Checklist. The

NAIC will not be sending their own checklist this year.

Electronic Filing is intended to be filing(s) submitted to the NAIC via the NAIC Internet Filing Site which eliminates the need for a company to submit diskettes or CD-ROM to the NAIC. Companies are not required to file hard copy filings with the NAIC.

Column (1) Checklist Companies may use the checklist to submit to a state, if the state requests it. Companies should copy the checklist and place an “x” in this column when submitting information to the state. Column (2) Line # Line # refers to a standard filing number used for easy reference. This line number may change from year to year. Column (3) Required Filings Name of item or form to be filed. The Annual Statement Electronic Filing includes the annual statement data and all supplements due March 1, per the Annual Statement Instructions. This includes all detail investment schedules and other supplements for which the Annual Statement Instructions exempt printed detail. The March.PDF Filing is the .pdf file for annual statement data, detail for investment schedules and supplements due March 1. The Risk-Based Capital Electronic Filing includes all risk-based capital data. The Risk-Based Capital.PDF Filing is the .pdf file for risk-based capital data. The Supplemental Electronic Filing includes all supplements due April 1, per the Annual Statement Instructions. The Supplemental.PDF Filing is the .pdf file for all supplemental schedules and exhibits due April 1. The Quarterly Electronic Filing includes the complete quarterly filing and the PDF files for all quarterly data. The Quarterly.PDF Filing is the .pdf file for quarterly statement data. The June.PDF Filing is the .pdf file for the Audited Financial Statements and Accountants Letter of Qualifications. Column (4) Number of Copies Indicates the number of copies that each foreign or domestic company is required to file for each type of form. The Blanks (EX) Task Force modified the 1999 Annual Statement Instructions to waive paper filings of certain NAIC supplements and certain investment schedule detail, if such investment schedule data is available to the states via the NAIC database. The checklists reflect this action taken by the Blanks (EX) Task Force. XXX appears in the “Number of Copies” “Foreign” column for the appropriate schedules and exhibits. Some states have chosen to waive printed quarterly and annual statements from their foreign insurers and have chosen to rely upon the NAIC database for these filings. This waiver could include supplemental annual statement filings. The XXX in this column might signify that the state has waived the paper filing of the annual statement and all supplements. ,

Attachment N


Column (5) Due Date Indicates the date on which the company must file the form. Column (6) Form Source This column contains one of three words: “NAIC,” “State,” or “Company,” If this column contains “NAIC,” the company must obtain the forms from the appropriate vendor. If this column contains “State,” the state will provide the forms with the filing instructions (generally, on the state web site). If this column contains “Company,” the company, or its representative (e.g., its CPA firm), is expected to provide the form based upon the appropriate state instructions or the NAIC Annual Statement Instructions. Column (7) Applicable Notes This column contains references to the Notes to the Instructions that apply to each item listed on the checklist. The company should carefully read these notes before submitting a filing. w:\qa\blanks\checklists\2020 filings made in 2021\1 hlthcklist_2020_filingsmade2021.docx

Attachment N

©2021 National Association of Insurance Commissioners 1 Life

LIFE, ACCIDENT AND HEALTH/FRATERNAL INSURERS


Contact: Telephone:


FRATERNAL COMPANIES BEGIN FILING LIFE/FRATERNAL STATEMENT EFFECTIVE WITH FIRST QUARTER, 2019. (1)

Checklist

(2)

Line #

(3)



(5)

DUE DATE

(6) FORM

SOURCE**

(7) APPLICABLE


I. NAIC FINANCIAL STATEMENTS 1 Annual Statement (8 ½”x14”) EO 3/1 NAIC 1.1 Printed Investment Schedule detail (Pages E01-E29) EO xxx 3/1 NAIC 2 Quarterly Financial Statement (8 ½” x 14”) EO 5/15, 8/15, 11/15 NAIC 3 Separate Accounts Annual Statement (8 ½”x14”) EO 3/1 NAIC II. NAIC SUPPLEMENTS 11 Accident & Health Policy Experience Exhibit EO 4/1 NAIC 12 Credit Insurance Experience Exhibit EO xxx 4/1 NAIC 13 Health Care Receivables Supplement EO xxx 3/1 131

4 Life, Health & Annuity Guaranty Association Assessable Premium Exhibit, Parts 1 and 2Assessment Base Reconciliation Exhibit

EO xxx 4/1 NAIC

14 Life, Health & Annuity Guaranty Assessment Base Reconciliation Exhibit Adjustment Form

EO xxx 4/1 NAIC

15 Long-term Care Experience Reporting Forms EO xxx 4/1 NAIC 16 Management Discussion & Analysis EO 4/1 Company 17 Medicare Supplement Insurance Experience Exhibit EO xxx 3/1 NAIC 18 Medicare Part D Coverage Supplement

EO 3/1, 5/15, 8/15, 11/15 NAIC

19 Risk-Based Capital Report EO 3/1 NAIC 20 Schedule SIS N/A N/A 3/1 NAIC 21 Supplemental Compensation Exhibit N/A N/A 3/1 NAIC 22 Supplemental Health Care Exhibit (Parts 1, 2 and 3) EO 4/1 NAIC 23 Supplemental Health Care Exhibit’s Allocation Report EO 4/1 NAIC 24 Supplemental Investment Risk Interrogatories EO 4/1 NAIC 25 Supplemental Schedule O EO xxx 3/1 NAIC 26 Supplemental Term and Universal Life Insurance

Reinsurance Exhibit

EO 4/1 NAIC

27 Trusteed Surplus Statement EO xxx

3/1, 5/15, 8/15, 11/15 NAIC

28 Variable Annuities Supplement EO 4/1 NAIC 29 VM 20 Reserves Supplement EO 3/1 NAIC 30 Workers’ Compensation Carve-Out Supplement EO 3/1 NAIC Actuarial Related Items 31 Actuarial Certification regarding use 2001 Preferred

Class Table

EO 3/1 Company

32 Actuarial Certification Related Annuity Nonforfeiture Ongoing Compliance for Equity Indexed Annuities

EO 3/1 Company

33 Actuarial Memorandum Related to Universal Life with Secondary Guarantee Policies required by Actuarial Guideline XXXVIII 8D

N/A xxx 4/30 Company

34 Actuarial Opinion EO 3/1 Company 35 Actuarial Opinion on Separate Accounts Funding

Guaranteed Minimum Benefit

EO 3/1 Company

36 Actuarial Opinion on Synthetic Guaranteed Investment Contracts

EO 3/1 Company

37 Actuarial Opinion on X-Factors EO 3/1 Company 38 Actuarial Opinion required by Modified Guaranteed

Annuity Model Regulation

EO 3/1 Company

39 Request for Life PBR Exemption (formerly Companywide Exemption)

E/O

Commissioner 7/1 NAIC 8/15 Company

40 Executive Summary of the PBR Actuarial Report N/A 4/1 Company 41 Life Summary of the PBR Actuarial Report N/A 4/1 Company 42 Variable Annuities Summary of the PBR Actuarial

Report

N/A 4/1 Company

43 PBR Actuarial Report (provide upon request) N/A Company

Attachment N

© 2021 National Association of Insurance Commissioners 2 Life

(1)

Checklist

(2)

Line #

(3)



(5)

DUE DATE

(6) FORM

SOURCE**

(7) APPLICABLE


44 RAAIS required by Valuation Manual N/A xxx 4/1 Company 45 Reasonableness & Consistency of Assumptions

Certification required by Actuarial Guideline XXXV

EO xxx 3/1,5/15, 8/15, 11/15 Company

46 Reasonableness of Assumptions Certification required by Actuarial Guideline XXXV

EO xxx

3/1,5/15, 8/15, 11/15 Company

47 Reasonableness & Consistency of Assumptions Certification required by Actuarial Guideline XXXVI (Updated Average Market Value)

EO xxx 3/1,5/15, 8/15, 11/15 Company

48 Reasonableness & Consistency of Assumptions Certification required by Actuarial Guideline XXXVI (Updated Market Value)

EO xxx 3/1,5/15, 8/15, 11/15 Company

49 Reasonableness of Assumptions Certification for Implied Guaranteed Rate Method required by Actuarial Guideline XXXVI

EO xxx 3/1,5/15, 8/15, 11/15 Company

50 RBC Certification required under C-3 Phase I EO 3/1 Company 51 RBC Certification required under C-3 Phase II EO 3/1 Company 52 Statement on non-guaranteed elements - Exhibit 5 Int.

#3

EO 3/1 Company

53 Statement on par/non-par policies – Exhibit 5 Int. 1&2 EO 3/1 Company III. ELECTRONIC FILING REQUIREMENTS 61 Annual Statement Electronic Filing xxx EO xxx 3/1 NAIC 62 March .PDF Filing xxx EO xxx 3/1 NAIC 63 Risk-Based Capital Electronic Filing xxx EO N/A 3/1 NAIC 64 Risk-Based Capital .PDF Filing xxx EO N/A 3/1 NAIC 65 Separate Accounts Electronic Filing xxx EO xxx 3/1 NAIC 66 Separate Accounts .PDF Filing xxx EO xxx 3/1 NAIC 67 Supplemental Electronic Filing xxx EO xxx 4/1 NAIC 68 Supplemental .PDF Filing xxx EO xxx 4/1 NAIC 69 Quarterly Statement Electronic Filing xxx EO xxx 5/15, 8/15, 11/15 NAIC 70 Quarterly .PDF Filing xxx EO xxx 5/15, 8/15, 11/15 NAIC 71 June .PDF Filing xxx EO xxx 6/1 NAIC IV. AUDIT/INTERNAL

CONTROL RELATED REPORTS 81 Accountants Letter of Qualifications EO N/A 6/1 Company 82 Audited Financial Reports EO 6/1 Company 83 Audited Financial Reports Exemption Affidavit N/A N/A Company 84 Communication of Internal Control Related Matters

Noted in Audit

EO N/A 8/1 Company


Financial Reporting

N/A N/A 8/1 Company

87 Notification of Adverse Financial Condition N/A N/A Company 88 Relief from the five-year rotation requirement for lead

audit partner

EO 3/1 Company

89 Relief from the one-year cooling off period for independent CPA

EO 3/1 Company

90 Relief from the Requirements for Audit Committees EO 3/1 Company 91 Request for Exemption to File Management’s Report

of Internal Control Over Financial Reporting

N/A N/A Company

V. STATE REQUIRED FILINGS 101 Corporate Governance Annual Disclosure*** 0 Company 102 Filings Checklist (with Column 1 completed) 0 State 103 Form B-Holding Company Registration Statement 0 Company 104 Form F-Enterprise Risk Report **** 0 Company 105 ORSA***** 0 Company 106 Premium Tax 0 State 107 State Filing Fees 0 State 108 Signed Jurat xxx 0 NAIC 109 Group Capital Calculation 0 110 111 112 113

Attachment N


(1)

Checklist

(2)

Line #

(3)



(5)

DUE DATE

(6) FORM

SOURCE**

(7) APPLICABLE





Attachment N


NOTES AND INSTRUCTIONS (A-K APPLY TO ALL FILINGS)


B Mailing Address:




F Late Filings:



I Amended Filings:



L Signed Jurat: M NONE Filings:


Attachment N





Electronic filing is intended to be filing(s) submitted to the NAIC via the NAIC Internet Filing Site which eliminates the need for a company to submit diskettes or CD-ROM to the NAIC. Companies are not required to file hard copy filings with the NAIC.

Column (1) Checklist Companies may use the checklist to submit to a state, if the state requests it. Companies should copy the checklist and place an “x” in this column when submitting information to the state. Column (2) Line # Line # refers to a standard filing number used for easy reference. This line number may change from year to year. Column (3) Required Filings Name of item or form to be filed. The Annual Statement Electronic Filing includes the annual statement data and all supplements due March 1, per the Annual Statement Instructions. This includes all detail investment schedules and other supplements for which the Annual Statement Instructions exempt printed detail. The March.PDF Filing is the .pdf file for annual statement data, detail for investment schedules and supplements due March 1. The Risk-Based Capital Electronic Filing includes all risk-based capital data. The Risk-Based Capital.PDF Filing is the .pdf file for risk-based capital data. The Separate Accounts Electronic Filing includes the separate accounts annual statement and investment schedule detail. The Separate Accounts.PDF Filing is the .pdf file for the separate accounts annual statement and all investment schedule detail. The Supplemental Electronic Filing includes all supplements due April 1, per the Annual Statement Instructions. The Supplement.PDF Filing is the .pdf file for all supplemental schedules and exhibits due April 1. The Quarterly Electronic Filing includes the quarterly statement data. The Quarterly.PDF Filing is the .pdf for quarterly statement data. The June.PDF Filing is the .pdf file for the Audited Financial Statements and Accountants Letter of Qualifications. Column (4) Number of Copies Indicates the number of copies that each foreign or domestic company is required to file for each type of form. The Blanks (EX) Task Force modified the 1999 Annual Statement Instructions to waive paper filings of certain NAIC supplements and certain investment schedule detail, if such investment schedule data is available to the states via the NAIC database. The checklists reflect this action taken by the Blanks (EX) Task Force. XXX appears in the “Number of Copies” “Foreign” column for the appropriate schedules and exhibits. Some states have chosen to waive printed quarterly and annual statements from their foreign insurers and to rely upon the NAIC database for these filings. This waiver could include supplemental annual statement filings. The XXX in this column might signify that the state has waived the paper filing of the annual statement and all supplements.

Attachment N


Column (5) Due Date Indicates the date on which the company must file the form. Column (6) Form Source This column contains one of three words: “NAIC,” “State,” or “Company,” If this column contains “NAIC,” the company must obtain the forms from the appropriate vendor. If this column contains “State,” the state will provide the forms with the filing instructions. If this column contains “Company,” the company, or its representative (e.g., its CPA firm), is expected to provide the form based upon the appropriate state instructions or the NAIC Annual Statement Instructions. Column (7) Applicable Notes This column contains references to the Notes to the Instructions that apply to each item listed on the checklist. The company should carefully read these notes before submitting a filing. w:\qa\blanks\checklists\2020 filings made in 2021\2 lifecklist_2020_filingsmade2021.docx

Attachment N

© 20210 National Association of Insurance Commissioners 1 Property/Casualty

PROPERTY & CASUALTY INSURERS


Contact: Telephone:


(1)

Checklist

(2)

Line #

(3)



(5)

DUE DATE

(6) FORM

SOURCE**

(7) APPLICABLE


I. NAIC FINANCIAL STATEMENTS 1 Annual Statement (8 ½” x 14”) EO 3/1 NAIC 1.1 Printed Investment Schedule detail (Pages E01-E29) EO xxx 3/1 NAIC 2 Quarterly Financial Statement (8 ½” x 14”) EO 5/15, 8/15,

11/15 NAIC

3 Protected Cell Annual Statement 0 xxx 3/1 NAIC 4 Combined Annual Statement (8 ½” x 14”) EO 5/1 NAIC

II. NAIC SUPPLEMENTS 11 Accident & Health Policy Experience Exhibit EO 4/1 NAIC 12 Actuarial Opinion EO 3/1 Company 13 Actuarial Opinion Summary N/A 3/15 Company 14 Bail Bond Supplement EO 3/1 NAIC 15 Combined Insurance Expense Exhibit EO 5/1 NAIC 16 Credit Insurance Experience Exhibit EO xxx 4/1 NAIC 17 Cybersecurity and Identity Theft Insurance

Coverage Supplement EO 4/1 NAIC

18 Director and Officer Insurance Coverage Supplement

EO 3/1, 5/15, 8/15, 11/15

NAIC

19 Financial Guaranty Insurance Exhibit EO 3/1 NAIC 20 Insurance Expense Exhibit EO xxx 4/1 NAIC 21 Life, Health & Annuity Guaranty Association

Assessablement Base Reconciliation Premium Exhibit, Parts 1 and 2

EO xxx 4/1 NAIC

22 Life, Health & Annuity Guaranty Assessment Base Reconciliation Exhibit Adjustment Form

EO xxx 4/1 NAIC

223 Long-Term Care Experience Reporting Forms EO xxx 4/1 NAIC 234 Management Discussion & Analysis EO 4/1 Company 245 Medicare Part D Coverage Supplement EO 3/1, 5/15,

8/15, 11/15 NAIC

256 Medicare Supplement Insurance Experience Exhibit EO xxx 3/1 NAIC 26 Mortgage Guaranty Insurance Exhibit EO xxx 4/1 NAIC 27 Premiums Attributed to Protected Cells Exhibit EO 3/1 NAIC 28 Private Flood Insurance Supplement EO 4/1 NAIC 29 Reinsurance Attestation Supplement EO xxx 3/1 Company 30 Exceptions to Reinsurance Attestation Supplement N/A xxx 3/1 Company 31 Reinsurance Summary Supplemental EO xxx 3/1 NAIC 32 Risk-Based Capital Report EO 3/1 NAIC 33 Schedule SIS N/A N/A 3/1 NAIC 34 Supplement A to Schedule T EO 3/1, 5/15,

8/15, 11/15 NAIC

35 Supplemental Compensation Exhibit N/A N/A 3/1 NAIC 36 Supplemental Health Care Exhibit (Parts 1, 2 and 3) EO 4/1 NAIC 37 Supplemental Health Care Exhibit’s Allocation

Report Supplement EO 4/1 NAIC

38 Supplemental Investment Risk Interrogatories EO 4/1 NAIC 39 Supplemental Schedule for Reinsurance

Counterparty Reporting Exception – Asbestos and Pollution Contracts

EO 3/1 NAIC

40 Trusteed Surplus Statement EO xxx 3/1, 5/15, 8/15, 11/15

NAIC

III. ELECTRONIC FILING REQUIREMENTS 61 Annual Statement Electronic Filing xxx EO xxx 3/1 NAIC 62 March .PDF Filing xxx EO xxx 3/1 NAIC 63 Risk-Based Capital Electronic Filing xxx EO N/A 3/1 NAIC 64 Risk-Based Capital .PDF Filing xxx EO N/A 3/1 NAIC 65 Combined Annual Statement Electronic Filing xxx EO xxx 5/1 NAIC

Attachment N


(1)

Checklist

(2)

Line #

(3)



(5)

DUE DATE

(6) FORM

SOURCE**

(7) APPLICABLE


66 Combined Annual Statement .PDF Filing xxx EO xxx 5/1 NAIC 67 Supplemental Electronic Filing xxx EO xxx 4/1 NAIC 68 Supplemental .PDF Filing xxx EO xxx 4/1 NAIC 69 Quarterly Statement Electronic Filing xxx EO xxx 5/15, 8/15,

11/15 NAIC

70 Quarterly .PDF Filing xxx EO xxx 5/15, 8/15, 11/15

NAIC


RELATED REPORTS

81 Accountants Letter of Qualifications EO N/A 6/1 Company 82 Audited Financial Reports EO 6/1 Company 83 Audited Financial Reports Exemption Affidavit N/A N/A Company 84 Communication of Internal Control Related Matters

Noted in Audit

EO

N/A 8/1

Company


Financial Reporting

N/A

N/A 8/1

Company

87 Notification of Adverse Financial Condition N/A N/A Company 88 Relief from the five-year rotation requirement for

lead audit partner

EO

3/1

Company

89 Relief from the one-year cooling off period for independent CPA

EO

3/1

Company

90 Relief from the Requirements for Audit Committees EO 3/1 Company 91 Request to File Consolidated Audited Annual

Statements N/A N/A Company

92 Request for Exemption to File Management’s Report of Internal Control Over Financial Reporting

N/A N/A Company

V. STATE REQUIRED FILINGS*** 101 Corporate Governance Annual Disclosure*** 0 Company 102 Filings Checklist (with Column 1 completed) 0 State 103 Form B-Holding Company Registration Statement 0 Company 104 Form F-Enterprise Risk Report **** 0 Company 105 ORSA ***** 0 Company 106 Premium Tax 0 State 107 State Filing Fees 0 State 108 Signed Jurat xxx 0 NAIC 109 Group Capital Calculation 0 110 111




Attachment N


NOTES AND INSTRUCTIONS (A-K APPLY TO ALL FILINGS) A Required Filings Contact Person:

B Mailing Address:




F Late Filings:



I Amended Filings:





Attachment N






Column (1) Checklist Companies may use the checklist to submit to a state, if the state requests it. Companies should copy the checklist and place an “x” in this column when submitting information to the state. Column (2) Line # Line # refers to a standard filing number used for easy reference. This line number may change from year to year. Column (3) Required Filings Name of item or form to be filed. The Annual Statement Electronic Filing includes the annual statement data and all supplements due March 1, per the Annual Statement Instructions. This includes all detail investment schedules and other supplements for which the Annual Statement Instructions exempt printed detail. The March .PDF Filing is the .pdf file for annual statement data, detail for investment schedules and supplements due March 1. The Risk-Based Capital Electronic Filing includes all risk-based capital data. The Risk-Based Capital.PDF Filing is the .pdf file for risk-based capital data. The Supplemental Electronic Filing includes all supplements due April 1, per the Annual Statement Instructions. The Supplemental.PDF Filing is the .pdf file for all supplemental schedules and exhibits due April 1. The Quarterly Statement Electronic Filing includes the complete quarterly statement data.

The Quarterly Statement.PDF Filing is the .pdf file for quarterly statement data.

The Combined Annual Statement Electronic Filing includes the required pages of the combined annual statement and the combined Insurance Expense Exhibit.

The Combined Annual Statement.PDF Filing is the .pdf file for the Combined annual statement data and the combined Insurance Expense Exhibit.

The June .PDF Filing is the .pdf file for the Audited Financial Statements and Accountants Letter of Qualifications. Column (4) Number of Copies

Indicates the number of copies that each foreign or domestic company is required to file for each type of form. The Blanks (EX) Task Force modified the 1999 Annual Statement Instructions to waive paper filings of certain NAIC supplements and certain investment schedule detail if such investment schedule data is available to the states via the NAIC database. The checklists reflect this action taken by the Blanks (EX) Task Force. XXX appears in the “Number of Copies” “Foreign” column for the appropriate schedules and exhibits. Some states have chosen to waive printed quarterly and annual statements from their foreign insurers and to rely upon the NAIC database for these filings. This waiver could include supplemental annual statement filings. The XXX in this column might signify that the state has waived the paper filing of the annual statement and all supplements.

Attachment N


Column (5) Due Date Indicates the date on which the company must file the form. Column (6) Form Source This column contains one of three words: “NAIC,” “State,” or “Company,” If this column contains “NAIC,” the company must obtain the forms from the appropriate vendor. If this column contains “State,” the state will provide the forms with the filing instructions. If this column contains “Company,” the company, or its representative (e.g., its CPA firm), is expected to provide the form based upon the appropriate state instructions or the NAIC Annual Statement Instructions. Column (7) Applicable Notes This column contains references to the Notes to the Instructions that apply to each item listed on the checklist. The company should carefully read these notes before submitting a filing. w:\qa\blanks\checklists\2020 filings made in 2021\3 propcklist_2020_filingsmade2021.docx

Attachment N

© 20210 National Association of Insurance Commissioners 1 Title

TITLE COMPANIES


Contact: Telephone:


(1)

Checklis

t

(2)

Line #

(3)

REQUIRED FILING FOR THE ABOVE STATE


(5)

DUE DATE

(6) FORM

SOURCE**

(7) APPLICABL

E NOTES Domestic Foreign

State NAIC State I. NAIC FINANCIAL STATEMENTS 1 Annual Statement (8 ½” x 14”) EO 3/1 NAIC 1.1 Printed Investment Schedule detail (Pages E01-

E29) EO xxx 3/1 NAIC 2 Quarterly Financial Statement (8 ½” x 14”)

EO 5/15, 8/15, 11/15 NAIC

II. NAIC SUPPLEMENTS 11 Actuarial Opinion EO 3/1 Company 12 Investment Risk Interrogatories EO 4/1 NAIC 13 Management Discussion & Analysis EO 4/1 Company 14 Schedule SIS N/A N/A 3/1 NAIC 15 Supplemental Compensation Exhibit N/A N/A 3/1 NAIC 16 Supplemental Schedule of Business Written By

Agency N/A 4/1 NAIC III. ELECTRONIC FILING

REQUIREMENTS 61 Annual Statement Electronic Filing xxx EO xxx 3/1 NAIC 62 March .PDF Filing xxx EO xxx 3/1 NAIC 63 Supplemental Electronic Filing xxx EO xxx 4/1 NAIC 64 Supplemental .PDF Filing xxx EO xxx 4/1 NAIC 65 Quarterly Statement Electronic Filing

xxx EO xxx 5/15, 8/15, 11/15 NAIC

66 Quarterly .PDF Filing xxx EO xxx

5/15, 8/15, 11/15 NAIC


RELATED REPORTS 81 Accountants Letter of Qualifications EO N/A 6/1 Company 82 Audited Financial Reports EO 6/1 Company 83 Audited Financial Reports Exemption Affidavit N/A N/A Company 84 Communication of Internal Control Related

Matters Noted in Audit EO N/A 8/1 Company 85 Independent CPA (change) N/A N/A Company 86 Management’s Report of Internal Control Over

Financial Reporting N/A N/A 8/1 Company 87 Notification of Adverse Financial Condition N/A N/A Company 88 Request for Exemption to File N/A N/A Company 89 Relief from the five-year rotation requirement for

lead audit partner EO 3/1 Company 90 Relief from the one-year cooling off period for

independent CPA EO 3/1 Company 91 Relief from the Requirements for Audit

Committees EO 3/1 Company V. STATE REQUIRED FILINGS*** 101 Corporate Governance Annual Disclosure*** 0 Company 102 Filings Checklist (with Column 1 completed) 0 State 103 Form B-Holding Company Registration

Statement 0 Company 104 Form F-Enterprise Risk Report *** 0 Company 105 ORSA **** 0 Company 106 State Filing Fees 0 State 107 Signed Jurat xxx 0 NAIC 108 Group Capital Calculation 0

Attachment N


(1)

Checklist

(2)

Line #

(3)

REQUIRED FILING FOR THE ABOVE STATE


(5)

DUE DATE

(6) FORM

SOURCE**

(7) APPLICABL

E NOTES Domestic Foreign

State NAIC State 109



****For those states that have adopted the NAIC updated Holding Company Model Act, a Form F Filing is required annually by holding company groups. Consistent with the Form B filing requirements, the Form F is a state filing only and should not be submitted by the company to the NAIC. Note however that this filing is intended to be submitted to the lead state. For more information on lead states, see the following NAIC URL: http://www.naic.org/public_lead_state_report.htm *****For those states that have adopted the NAIC Risk Management and Own Risk and Solvency Assessment Model Act, a summary report is required annually by insurers and insurance groups above a specified premium threshold. The ORSA Summary Report is a state filing only and should not be submitted by the company to the NAIC. Note however that this filing is intended to be submitted to the lead state if filed at the insurance group level. For more information on lead states, see the following NAIC URL: http://www.naic.org/public_lead_state_report.htm

Attachment N


NOTES AND INSTRUCTIONS (A-K APPLY TO ALL

FILINGS)


B Mailing Address:




F Late Filings:



I Amended Filings:





Attachment N






Column (1) Checklist Companies may use the checklist to submit to a state, if the state requests it. Companies should copy the checklist and place an “x” in this column when submitting information to the state. Column (2) Line # Line # refers to a standard filing number used for easy reference. This line number may change from year to year. Column (3) Required Filings Name of item or form to be filed. The Annual Statement Electronic Filing includes the annual statement data and all supplements due March 1, per the Annual Statement Instructions. This includes all detail investment schedules and other supplements for which the Annual Statement Instructions exempt printed detail. The March.PDF Filing is the .pdf file for the annual statement, detail for investment schedules and all supplements due March 1. The Supplemental Electronic Filing includes all supplements due April 1, per the Annual Statement Instructions. The Supplemental.PDF Filing is the .pdf file for all supplements due April 1. The Quarterly Electronic Filing includes the quarterly statement data. The Quarterly.PDF Filing is the .pdf for quarterly statement data. The June.PDF Filing is the .pdf file for the Audited Financial Statements and Accountants Letter of Qualifications. Column (4) Number of Copies Indicates the number of copies that each foreign or domestic company is required to file for each type of form. The Blanks (EX) Task Force modified the 1999 Annual Statement Instructions to waive paper filings of certain NAIC supplements and certain investment schedule detail, if such investment schedule data is available to the states via the NAIC database. The checklists reflect this action taken by the Blanks (EX) Task Force. XXX appears in the “Number of Copies” “Foreign” column for the appropriate schedules and exhibits. Some states have chosen to waive printed quarterly and annual statements from their foreign insurers and to rely upon the NAIC database for these filings. This waiver could include supplemental annual statement filings. The XXX in this column might signify that the state has waived the paper filing of the annual statement and all supplements. Column (5) Due Date Indicates the date on which the company must file the form. Column (6) Form Source This column contains one of three words: “NAIC,” “State,” or “Company,” If this column contains “NAIC,” the company must obtain the forms from the appropriate vendor. If this column contains “State,” the state will provide the forms with the

Attachment N


filing instructions (generally, on its web site). If this column contains “Company,” the company, or its representative (e.g., its CPA firm), is expected to provide the form based upon the appropriate state instructions or the NAIC Annual Statement Instructions. Column (7) Applicable Notes This column contains references to the Notes to the Instructions that apply to each item listed on the checklist. The company should carefully read these notes before submitting a filing. w:\qa\blanks\checklists\2020 filings made in 2021\4 titlecklist_2020_filingsmade2021.docx

Attachment N

© 2020 2021 National Association of Insurance Commissioners 1

General Instructions For States to Complete Checklist

Each checklist is divided into five sections. The first section contains the major NAIC filings. The second section lists all of the NAIC supplements, whether they are to be bound into the statement or not. The third section lists items to be filed electronically with the NAIC. The fourth section is a list of all of the filings related to the audited financial statements. The fifth section lists state-specific filing requirements. The items in the first four sections should remain in the same order as the examples. This will enable companies to locate common information about a particular filing from each state. Finally, there is a section of notes to the instructions. The purpose of the Notes is to provide companies with state-specific information in a standard format. You may require more notes than provided; however, the first notes should remain in the same order and format for each state. Each state-specific note should contain state-specific instructions where any state deviates from specific NAIC instructions. The state should mail the company instructions to companies along with the checklist or post these instructions to its website. New requirements or changes to the checklists will be highlighted for your convenience.

Please Note: Your state’s requirements for companies to file with the NAIC should be incorporated into this Checklist.

Column 1 Checklist

This column provides the company a method for marking completed forms or filings.

Column 2 Line #

Refers to a standard filing number used for easy reference and which may change from year to year, but should remain the same between states (i.e., number 61 - Annual Statement Electronic Filing is the same for all jurisdictions.). States may expand the State Required Filings Section to include up to 100 filings required by any individual state.

Column 3 Required Filings

Name of item or form to be filed. Each section is alphabetized. Please note that the items shown under “State Required Filings” may not apply to your state. The items included are those that a significant number of states require. Please add your state-specific filings in Section V.

Form B – Holding Company Registration Statement, Form F – Enterprise Risk Report and ORSA Group Capital Calculation has have been added to the “State Required Filings” section of the checklist.

If more than one state page is required from each company, please insert this requirement under “State Required Filings.” Likewise, if your state requires the Risk-Based Capital from your domestic companies to be filed with you in addition to companies filing this with the NAIC, please insert this requirement under “State Required Filings.”

The 1999 Annual Statement Instructions were modified to waive paper filings of certain NAIC supplements (those supplements previously included in the Electronic Filing Pilot Project) and certain investment schedule detail, if such investment schedule data is available to the states via the NAIC database. The checklists have been modified to reflect this action taken by the Blanks (EX) Task Force. XXX appears in the “Number of Copies” “Foreign” column for the appropriate schedules and exhibits. If you are deviating from the Annual Statement Instructions and wish to have these items filed in hard copy with your department, you should remove XXX from this column and insert the number of copies required. You should also make a note to companies that an additional copy is not required if these schedules are bound in the Annual Statement.

Column 4 Number of Copies

This column indicates the number of copies that a foreign or domestic company is required to file for each type of form. The 1999 Annual Statement Instructions were modified to exclude the requirement for filing paper copies of investment schedules from foreign companies if the data is captured on the NAIC database. The 1999 Annual Statement Instructions were modified to include the supplements that were part of the Electronic Filing Pilot. An XXX appears in the foreign column, if the schedule or supplement is included in either of these instructions. If you require paper copies of these schedules or supplements, you should remove XXX from this column and insert the number of copies required. An N/A appears in this column if the filing is only required with the state of domicile according to the NAIC Annual Statement Instructions. This does not preclude any state from requesting these documents from any company. If you wish to request the documents, simply remove the XXX or N/A and insert the number of copies that you require.

Column 5 Due Date

Attachment N


Due Date indicates the date a filing is required with the state insurance regulatory authority. If you do not require a specific filing, please replace the date with XXX. Use Note E to explain any other filing instructions regarding due dates.

Column 6 Form Source

This column contains one of three words: “NAIC,” “State,” or “Company,” If this column contains “NAIC,” the company must obtain the forms from the appropriate vendor. If this column contains “State,” the state will provide the forms with the filing instructions. If this column contains “Company,” the company, or its representative (e.g., its CPA firm), is expected to provide the form based upon the appropriate state instructions or the NAIC Annual Statement Instructions. Insert a “#” sign after the form source where the state has changed the requirements since last year or the item is a new NAIC blank. Do not insert a “#” sign if the NAIC blank has changed, as this would lead to many “#” signs, making its use somewhat meaningless.

Column 7 Applicable Notes

This column contains references to the Notes and Instructions that apply to each item. However, Notes A-K apply to all filings.

Item 85

Insert specific instructions related to appointment or change in Independent CPA.

Attachment N

© 2020 2021 National Association of Insurance Commissioners 3

Instructions and Suggested Language for the Notes General: 1. Suggested language for each note should be used to the extent possible. 2. Some of the suggested language covers different ideas, for example, note E has several different issues that could apply.

Where appropriate, combine language. 3. Where appropriate, list each item and special instructions (see notes H and K, for examples) 4. Examples for notes are shown in italics and should be replaced by your state-specific instructions. Note A ...... should provide the name(s), email address(es) and phone number(s) of a person that companies may contact with

questions regarding filings. If there is more than one person, please indicate the types of calls each person takes, in addition to their name and number.

Note B ...... should list the mailing address, and hand delivery address (if different) for required filings. Note C ...... should provide specific information related to the amount(s) and mailing address for filing fees. Note D ...... should list the mailing address for premium taxes (and a contact if appropriate). If your state has a different

Department collect premium taxes (not the Department that collects other insurance information, fees), please indicate that Department, and provide a contact name if possible.

Note E ...... should contain instructions on delivery dates, and any other special delivery instructions: .................. E-1 All filings must be physically received at one of the addresses in Note B no later than the indicated

due date. .................. .................. All items must be mailed U.S. mail. .................. .................. If the due date falls on a weekend or holiday, then the deadline is extended to the next business day. .................. .................. or .................. .................. E-2 All filings must be postmarked no later than the indicated due date. .................. .................. All items must be mailed U.S. mail. .................. .................. If the due date falls on a weekend or holiday, then the deadline is extended to the next business day. Note F ...... should describe any penalties for late filings .................. Companies will be fined $100 per day for a late filing. .................. .................. Company’s license may be suspended if the annual statement is received more than 30 days late. Note G ...... should contain language on original signatures: .................. Original signatures required on all filings from domestic companies. Foreign companies should follow the

instructions in the NAIC Annual Statement Instructions. .................. .................. Original signatures required on all filings that require signatures.

Attachment N


Note H ...... should contain other signature/notarization/certification instructions. These are examples and should be updated according to your state’s current requirements.: .................. The following officers are required to sign the annual statement: .................. CEO; President; Treasurer .................. .................. Special instructions: .................. Reinsurance Summary Statement --must be notarized Note I ....... should contain instructions on filing amended filings. .................. Amended items must be filed within 10 days of their amendment, along with an explanation of the

amendments. If there are signature requirements for the original filing, same should be followed for any amendment.

Note J ....... should contain instructions for companies to request an exemption or extension to a filing .................. Foreign companies must supply a written copy of any exemption or extension received by its state of domicile

at least 10 days prior to the filing due date to receive such from Minnesota. Domestic companies should apply at least 30 days prior to the due date.

Note K ...... should contain instructions on bar codes .................. Please use the bar codes supplied by Florida. .................. .................. or .................. .................. Please follow the instructions in the NAIC Annual Statement Instructions. .................. .................. or .................. .................. Bar codes for Minnesota filings should be generated according to NAIC instructions. The codes are: Certificate of Deposit .............................................................................................................. 003 Credit Insurance Annual Report ............................................................................................ 004 Form 10K ................................................................................................................................ 005 Independent Actuarial Opinion .............................................................................................. 006 Investment Policy Certification .............................................................................................. 007 Non comprehensive Accident & Health Exhibit .................................................................... 008 Report by Independent CPA Regarding Application of Valuation Procedures .................... 009 Report on Evaluation of Accounting Procedures and System of Internal Control ............... 010 Report of Ratio of Qualified Assets to Required Liabilities ................................................... 011 Note L ...... should have instructions for filing Signed Jurat page .................. .................. If the state requires the filing of a Signed Jurat page for foreign companies, please indicate. Note M ..... should have instructions for NONE filings .................. If the state requires the filing of a “NONE” page, please indicate. .................. .................. See NAIC Annual Statement Instructions for Supplemental Interrogatories. Exceptions to these instructions

are noted on the form. Note N ...... Filings New, Discontinued or Materially Modified since last year. .................. None of the filings have been discontinued since last year .................. .................. No longer required: .................. Listing of new Reinsurers

Attachment O


Blanks (E) Working Group Summary of Comments for November 16, 2018

Conference Call

ITEMS RECEIVED FOR COMMENT

Reference Number Description

2021-11BWG Add a new annual statement supplement to capture exposure data for Annual Statement Lines 4, 19.1, 19.2 and 21.2. Add a column to the Quarterly Parts 1 and 2 to capture exposure data for these annual statement lines for the quarter.

Comment #1 – Industry Interested Parties Attachment P Page 1&2 of 6

IPs recommend rejection of this exposure for the following primary reasons: • The Statistical Data (C) Working Group confirmed for CASTF that industry-level aggregate premium and exposure counts by state cou ld be

published 12-13 months sooner than the current full reports, with 90-99% of the current data being received by November f rom their 22 submitters, without disruption to financial reporting requirements or systems. Data collection points were described as follows:

(See Full Comment Letter for Details)

• Regulators have commented that average premium per exposure by quarter does not add value because this average does not change much even

year to year.

(See Full Comment Letter for Details)

Comment # 2 – COPLFR Attachment P Page 1 through 3 of 4

The proposal provides Generic comments related to 2021-11BWG and 2021-2021-13BWG related to potent ial benefit s, level o f detail o f data requested and value of reported data. It also provides specific comments on to 2021-11BWG related to definition of exposure, calendar date alignment, existing alternat ive data sources and suggested changes to proposal. (See Full Comment Letter for Details)

Attachment O



Comment # 3 – – Center for Economic Justice Attachment P Page 1 through 9 of 9 The comment letter supports adoptions of the proposal. The letter lays out 10 items in its summary and then includes a more detailed discussion onf

the following.

• 2021-11BWG is consistent with and furthers the goals articulated in the NAIC State Ahead strategy.

• Use and Value of 2021-11BWG to Financial Analysts, Market Analysts, Policymakers and the Public.

• Contrary to industry claims, the additional data elements – and average premium calculations generated – will not be misleading to regulators, policymakers or the public.

• The additional data elements are financial information suited to reporting through the annual and quarterly financial statements –

comprehensive, uniform.

• By virtue of financial statement reporting, 2021-11BWG includes some data quality checks.

• There will be a non-material cost burden on insurers to report the additional data elements. (See Full Comment Letter for Details)

Comment # 4 – CASTF Attachment P Page 1 through 4 of 4

CASTF submitted two documents in response to the BWG referral. One is a survey of its members regarding support or opposition to the p roposal with comments from some members regarding their answer. The other document is from the Statistical Data Working Group regarding whether the timeline for speeding up the receipt of premium and exposure data from outside parties. (See Full Comment Letter for Details)

Attachment O



2021-12BWG

Add and delete lines on the Analysis of Operations by Lines of Business – Accident and Health for Life\Fraternal to ca pture health specific data captured on the Heath Analysis of Operations by Lines of Business but not on the Life\Fraternal Analysis of Operations page and add new crosschecks for the new lines. Add new crosschecks to the Analysis of Operations by Lines of Business – Summary to map the lines on the accident and health page to the summary.

Comment #1 – Industry Interested Parties Attachment P Page 2 of 6

IPs have collaborated with State Regulators and NAIC Staff in reviewing the comments received on this exposure. Based on these d iscussions, we support the suggestion that this item be withdrawn, and a new item be exposed to address consistent reporting of the accident a nd health lines o f business on the Analysis of Operations by Lines of Business page. IPs will review and provide comments on the new exposure.

2021-13BWG Add a new supplement to capture premium and loss data for Annual Statement Lines 17.1, 17.2 & 17.3 of the Exhibit of Premiums and Losses (State Page) – Other Liability by more granular lines of business.

Comment #1 – Industry Interested Parties Attachment P Page 2, 3 & 6 of 6

IPs have the following comments and recommend a deferral and re-exposure of this item to allow additional time to evaluate the proposed alternative changes to the Property statement. Letter comments on the following:

• Cost to prepare versus benefit.

• Recommends reduced format.

• Rationale of reduced number of columns.

• Basis of category lines used in proposal.

• How products are constructed and data captured by industry. (See Full Comment Letter for Details)

Attachment O



Comment # 2 – COPLFR Attachment P Page 1 through 4 of 4

The proposal provides Generic comments related to 2021-11BWG and 2021-2021-13BWG related to potent ial benefit s, level o f detail o f data requested and value of reported data. It also provides specific comments on to 2021-13BWG related to granularity and definition, credibility/Quality (I BNR), inconsistency with the underlying policies, preparation and suggested changes to proposal. (See Full Comment Letter for Details)

2021-14BWG Expanded the number of lines of business reported on Schedule H to match the lines of business reported on the Health Statement. Modif ied the instructions so they will be uniform between life/fraternal and property.

Comment #1 – Industry Interested Parties Attachment P Page 4&5 of 6

IPs provide comments on suggested changes to proposal. (See Full Comment Letter for Details)

Attachment P

Page | 1

Tip Tipton, CPA Accounting Policy Lead Thrivent Phone : 612.844.7298 Email : [email protected]

Randy Hefel Senior Regulatory Specialist SOVOS Phone: 319.739.3528 Email: [email protected]

October 22, 2021 Mr. Jake Garn, Chair Blanks Working Group National Association of Insurance Commissioners 1100 Walnut St. Kansas City, MO 64106 SUBJECT: Blanks Working Group (“BWG”) proposals exposed during the conference call on July 22, 2021 Dear Mr. Garn: Interested Parties (“IPs”) appreciate the opportunity to review and comment on the 4 proposals that were re-exposed during a conference call by BWG on Thursday, July 22, 2021.

2021-11 [Re-exposed changes to add a new annual statement supplement in the Property/Casualty Statement to capture direct exposures written and direct exposures earned which will be reported for Annual Statement Lines 4, 19.1, 19.2 and 21.2; also, add a column to the Quarterly Parts 1 and 2 to capture exposure data for these annual statement lines for the quarter. Anticipated effective date is Annual 2022 / 1st Quarter 2023]

IPs recommend rejection of this exposure for the following primary reasons: • The Statistical Data (C) Working Group confirmed for CASTF that industry-level aggregate

premium and exposure counts by state could be published 12-13 months sooner than the current full reports, with 90-99% of the current data being received by November from their 22 submitters, without disruption to financial reporting requirements or systems. Data collection points were described as follows: Homeowners (based on percent of premium previously reported) o 32% could report by end of May o 60% by end of August o 99% by end of November Auto database (based on percent of premium previously reported) o 32% could report by end of May o 49% by end of August o 91% by end of November (Texas data not available until January)

• Regulators have commented that average premium per exposure by quarter does not add value because this average does not change much even year to year.

Attachment P

Page | 2

• This is not appropriate data for collection via the financial statements. o Financial data deals with the dollars; and statistical data, specifically discrete data,

includes widget count, such as exposure count. Exposure count and average premium per exposure are associated with rate oversight, not f inancial reporting, or insurer solvency.

o The due dates of f inancial statements require quarterly filings in 45 days and annual statements in 60 days. Statistical agencies currently contributing this data to CASTF indicated a need of 2 months for data quality checks and analysis.

o Exposure count being publicly available by state and product at a company level would avail sensitive, if not confidential, company data, which we believe is not desired by the NAIC.

2021-12 [Re-exposed changes to modify the Analysis of Operations by Lines of Business – Accident and Health for Life\Fraternal entities by adding and deleting lines to capture health specific data captured on the Heath Analysis of Operations by Lines of Business but not on the Life\Fraternal Analysis of Operations page; also, add new crosschecks for the new lines and new crosschecks to the Analysis of Operations by Lines of Business – Summary to map the lines on the accident and health page to the summary. The purpose of the proposal is to modify the Analysis of Operations by Lines of Business – Accident and Health for Life\Fraternal entities to capture health specific data points captured on the Health Analysis of Operations page. Anticipated effective date is Annual 2022]

IPs have collaborated with State Regulators and NAIC Staff in reviewing the comments received on this exposure. Based on these discussions, we support the suggestion that this item be withdrawn, and a new item be exposed to address consistent reporting of the accident and health lines of business on the Analysis of Operations by Lines of Business page. IPs will review and provide comments on the new exposure.

2021-13 [Re-exposed changes to add a new supplement (Exhibit of Other Liabilities By Lines Of Business) to the Property annual statement to capture premium and loss data for Annual Statement Lines 17.1, 17.2 & 17.3 of the Exhibit of Premiums and Losses (State Page) – Other Liability to provide regulators more granular detail of the premium and losses of the diverse lines of business reported on such lines. Anticipated effective date is Annual 2022]

IPs have the following comments and recommend a deferral and re-exposure of this item to allow additional time to evaluate the proposed alternative changes to the Property statement. • IPs believe that the cost to the industry preparing the data requested at the proposed level

of granularity would exceed the benefit primarily due to the immaterial amounts associated with the lines of business.

• We would recommend consideration be given to a reduced format to identify the more material lines of business. Once this is created, regulators could evaluate the results and request additional detailed information from individual entities on a case-by-case basis. Refer to Attachment 1 for the example.

Attachment P

Page | 3

• The following is the rationale for the reduced number of columns: o Earned Premiums as suggested for removal as earned premiums include EBUB (Earned

But Unbilled premiums). EBUB is an estimate of the portion of future written premium that covers past periods (e.g., due to late booking of installments and audit premiums). Such an estimate is generally only made at an aggregate level and not at the subline level being requested. Allocations of estimates are inherently less reliable and can be arbitrary and misleading information. Written premiums in contrast can be tracked to individual policies and should be sufficient premium information for regulators to identify the products being written.

o Incurred losses (& LAE) and loss (& LAE) reserves that include IBNR would similarly include allocations of aggregate estimates not amenable to reliable allocation to subline. As such, information that includes those allocations can be arbitrary, unreliable, and not necessary to achieve the stated objective (of the regulatory desire to understand the sources of risk in the Other Liability line).

o In LAE in particular, part of those expenses represents “Adjusting & Other”, which is an estimate of future claim handling costs related to outstanding claims. That estimate is typically related to future claim adjuster budgets, which are generally only made at a broad level (as claim adjusters for a product line may be involved in many different sublines). As such, claim handling costs are not amenable to consistently reliable subline allocation.

o With regard to the Defense & Cost Containment (DCC) portion of LAE, while paid DCC can be tracked to individual claims (and hence subline), not all insurers produce case estimates for such costs. Therefore, data that contains DCC case reserves would not be comparable across the industry.

• The current proposal seems to be based on the current definition of Other Liability found in

the Annual Statement Instructions. That definition seems to be a mix of general industry definitions (e.g., day care, SIC code designations) and coverage definitions (e.g., professional liability) with no consistent theme or structure. As such, it does not map well to how current business reported in the Other Liability is structured or sold. The result would be inconsistent and non-comparable reporting across the industry, with many judgments required and, in some cases, arbitrary assignments made to achieve the mapping. In some cases, we consider the current proposed sublines to be duplicative (e.g., sublines 6 and 28 for Errors & Omissions), and in some cases we consider the proposed sublines to be erroneous (e.g., Cyber policies may include Internet Liability, so these sublines should be combined). That is why we consider a data call or some other form of additional research to be necessary before proceeding with this proposal. Any subline list should have a consistent theme or structure for the sublines requested.

• IPs are also concerned that any subline split will be flawed due to the variation in how

products are constructed, and data captured across the industry. It is likely impossible for any subline split to meet the stated objective for the insurance industry, as the subline categories are likely to be too granular for some and too broad for others. We recommend instead that the NAIC consider data calls as part of the regular financial examination process. Such a data call would identify the material (if any) Other Liability sublines for a particular insurer, which could then lead to interim monitoring of the areas of concern where deemed warranted. This would avoid a broad-brush approach applied to the entire industry that would add compliance costs but still not meet the stated goals.

Attachment P

Page | 4

2021-14 [Re-exposed changes to expand the number of lines of business reported on Schedule H (Accident and Health Exhibit) to match the lines of business reported on the Health Statement and modify the instructions to be uniform between life/fraternal and property. The purpose of the proposal is to bring uniformity in the accident and health lines of business used on Schedule H with other schedules and exhibits in the annual statement. Anticipated effective date is Annual 2022]

IPs have the following additional comments: On page 2 of the PDF the header should include Property insurers:

• ANNUAL STATEMENT INSTRUCTIONS – LIFE\FRATERNAL AND PROPERTY

Throughout the exposure, the crosschecks in the Property Instructions refer to ‘Lines’ in another exhibit but there is only 1 line that is included. IPs believe this should be changed to reflect either a single line (e.g. Line) or multiples lines (e.g. Lines) for clarity. See example below from page 4 of the PDF:

• Column 3 – Line 4 plus Line 8 should agree with the Insurance Expense Exhibit, Part II (Column 9 + Column 11 + Column 27 and 29), Lines 13.1.

Throughout the exposure, the crosschecks in the Property Instructions refer to several ‘Columns’ in referencing another exhibit in various ways. IPs believe this should be changed for consistency (e.g. Columns 9 + 11 + 27 + 29). See example below from page 4 of the PDF:

• Column 3 – Line 4 plus Line 8 should agree with the Insurance Expense Exhibit, Part II (Column 9 + Column 11 + Column 27 and 29), Lines 13.1.

On page 4 of the PDF, the Property crosscheck for Part 1, Line 4, Column 9 (Vision Only) should refer to Line 15.1 (Vision Only) not Line 15.5 (Medicaid Title XIX). On page 6 of the PDF, the Property crosscheck for Part 1, Line 7, Column 9 (Vision Only) should refer to Line 15.1 (Vision Only) not Line 15.5 (Medicaid Title XIX). On page 7 of the PDF, the Property crosscheck for Part 1, Line 9, Column 9 (Vision Only) should refer to Line 15.1 (Vision Only) not Line 15.5 (Medicaid Title XIX). On page 8 of the PDF, the Property crosscheck for Part 1, Line 13, Column 9 (Vision Only) should refer to Line 15.1 (Vision Only) not Line 15.5 (Medicaid Title XIX). On page 9 of the PDF, the Property crosscheck for Part 2, Line 3, Column 5 (Vision Only) should refer to Line 15.1 (Vision Only) not Line 15.5 (Medicaid Title XIX). On page 9 of the PDF, there are 2 Property crosschecks for Part 2, Line 3, Column 9. The first one should refer to Column 8 (Medicare Title XVIII) not Column 9. On page 13 of the PDF, the Property crosscheck for Part 5, Line 4, Column 4 (Vision Only) should refer to Line 15.1 (Vision Only) not Line 15.5 (Medicaid Title XIX). On page 14 of the PDF, the Property crosscheck for Part 5, Line 8, Column 4 (Vision Only) should refer to Line 15.1 (Vision Only) not Line 15.5 (Medicaid Title XIX). On page 15 of the PDF, the Property crosscheck for Part 5, Line 12, Column 4 (Vision Only) should refer to Line 15.1 (Vision Only) not Line 15.5 (Medicaid Title XIX).

Attachment P

Page | 5

On page 49 of the PDF, the following lines in Part 2 refer to prior year values which would cause crosscheck issues as they are not in the new columnar layout:

o Section A, Line 5 – Total premium reserves, prior year o Section B, Line 4 – Total contract reserves, prior year o Section C, Line 2 – Total prior year

On page 51 of the PDF, the following lines in Part 5 refer to prior year values which would cause crosscheck issues as they are not in the new columnar layout:

o Section A, Line 2 – Beginning claim reserves and liabilities o Section B, Line 6 – Beginning claim reserves and liabilities o Section C, Line 10 – Beginning claim reserves and liabilities o Section E, Line 18 – Beginning claim reserves and liabilities

In order to accommodate the above crosscheck issues on pages 49 and 51, IPs suggest adding reporting guidance for this item as follows:

“For Annual 2022 reporting, the prior year amounts should be entered manually. Beginning with Annual 2023 reporting, the prior year amounts will pull from the prior year annual statement.”

On page 51 of the PDF, the existing line numbering in Part 5 is inconsistent with the existing line numbering of the other Parts in Schedule H. In Part 5, the numbering continues through to the next section whereas in the other Parts, the numbering begins with each new section. We recommend that Part 5 numbering be changed to align with the other Parts.

Tip Tipton, CPA Randy Hefel Accounting Policy Lead NAIC Liaison Thrivent SOVOS CC: Kim Hudson, Vice-Chair, California

Mary Caswell, NAIC Calvin Ferguson, NAIC Keith Bell, Travelers Rose Albrizio, Equitable Financial

Attachment P

6

ANNUAL STATEMENT BLANK – PROPERTY SUPPLEMENT FOR THE YEAR OF THE

EXHIBIT OF OTHER LIABILITIES BY LINES OF BUSINESS AS REPORTED ON LINE 17 OF THE EXHIBIT OF PREMIUMS AND LOSSES

(To Be Filed by March 1) NAIC Group Code ......................................... NAIC Company Code......................................................

Compan y Nam e ............. ... ... .. ... ... ... .. ... ... .. ... ... .. ... ... .. ... ... .. ... ... .. ... ... .. ... ... .. ... ... ... .. ... ... .. ... ... .. ... ... .. ... ... .. ... ... .. ... ... .. ... ... ... .. ... ... .. ... ... .. ... ... .. ... ... .. ... ... .. .. ............. ... ... ... .. ... ... .. ... ... .. ... ... .. ... ... .. ... ... .. ... ... .. ... ... .. ... ... ... .. ... ... .. ... ... .. ... ... .. ... ... .. ... ... ..

Direct Business Only 1

Premiums Written 2

Paid Losses 3

Case Basis Outstanding Losses 1. Professional Liability 2. Directors and Officers Liability 3. Excess Casualty and Umbrella Liability 4. Environmental / Pollution Liability 5. General Liability 6. Employment Practices Liability 7. Contractual Liability 8. All Other 9. Total ASL 17 – Other Liability (Sum of Lines 1-8)

Column 1 = Line 9 should equal Exhibit of Premiums and Losses Grand Total Page Column 1, Line 17.1 + Line 17.2 + Line 17.3 Column 2 = Line 9 should equal Exhibit of Premiums and Losses Grand Total Page Column 5, Line 17.1 + Line 17.2 + Line 17.3 Column 2 = Line 9 would not equal an existing column from the Exhibit of Premiums and Losses Grand Total Page

Row # Proposed Line of Business Existing Line of Business (per Appendix – P&C Lines of Business)

1 Professional Liability 6. Errors and Omissions Liability Professional Liability Other Than Medical and 28. Professional Errors and Omissions Liability

2 Directors and Officers Liability 16. Directors and Officers Liability 3 Excess Casualty and Umbrella Liability 8. Excess and Umbrella Liability 4 Environmental / Pollution Liability 7. Environmental Pollution Liability 5 General Liability 13. Commercial General Liability 6 Employment Practices Liability 19. Employment Practices Liability 7 Contractual Liability 4. Contractual Liability 8 Other All other lines not identified above

1850 M Street NW Suite 300 Washington, DC 20036 Telephone 202 223 8196 Facsimile 202 872 1948 www.actuary.org

Attachment P

1

October 21, 2021

Jacob Garn Chair Blanks (E) Working Group National Association of Insurance Commissioners (NAIC)

c/o: Mary Caswell [email protected]

Calvin Ferguson [email protected]

Re: 2021 NAIC Blanks Proposals 2021-11BWG and 2021-13BWG Exposed for Public Comment

Dear Mr. Garn:

On behalf of the Committee on Property and Liability Financial Reporting (COPLFR) of the American Academy of Actuaries,1 I appreciate this opportunity to provide updated comments on the proposed changes to the financial requirements by the National Association of Insurance Commissioners (NAIC) Blanks (E) Working Group, exposed for public comment on July 22, 2021, with comments due back by October 22, 2021. The comments in this letter largely reflect our comments provided in June, which still stand with minor adjustments to reflect the modified exposure draft 2021-11BWG.

COPLFR appreciates your consideration of our comments.

The Blanks Working Group has exposed two proposals that we would like to provide comment on.

I. 2021-11BWG- Add a new annual statement supplement to the Property and Casualty (P/C) statement to capture exposure data for Annual Statement Lines 2.5, 4, 19.1, 19.2 and 21.2 of the Exhibit of Premiums and Losses. Add a column to the Quarterly Parts 1 and 2 to capture

1 The American Academy of Actuaries is a 19,500-member professional association whose mission is to serve the public and the U.S. actuarial profession. For more than 50 years, the Academy has assisted public policymakers on all levels by providing leadership, objective expertise, and actuarial advice on risk and financial security issues. The Academy also sets qualification, practice, and professionalism standards for actuaries in the United States.

http://www.actuary.org/

mailto:[email protected]



Attachment P

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exposure data for these annual statement lines for the quarter. Comment Deadline 10/22/2021

II. 2021-13BWG- Add a new supplement to capture premium and loss data for Annual Statement

Lines 17.1, 17.2 and 17.3 of the Exhibit of Premiums and Losses (State Page) – Other Liability by more granular lines of business. Comment Deadline 10/22/2021

We believe that the potential benefit that may be derived by the public from having access to additional reported information needs to be considered relative to the effort to obtain the additional information. We also believe that the quality and consistency of the data that would be provided under the proposals are a concern, and that the proposals should ensure the additional data will serve the intended use.

The level of detail that would be requested by the two exposure drafts is not regularly captured in typical company financial data systems. It will require time for each company to clarify the detailed requirements and then additional lead time to implement within individual company systems to ensure quality data can be provided.

The value of the reported data will depend on what is available from each specific company. Additional granularity of some data may still only be achieved through judgment and allocations made at the individual company level. This often makes detailed information less valuable once obtained and aggregated to the industry level. In addition, requesting data with unclear requirements and with definitions not commonly used across the industry is not likely to produce consistent and useful quality data.

Specific issues that we would like to point out, given the currently provided details of these two proposals, are separately discussed below.

2021-11BWG

• Definition of exposure—A clearer definition of how exposure should be calculated for each requested line is needed. Some lines where this additional information is requested contain significant issues related to mix of exposure.

o For example, the exposure for an auto policy having Comprehensive & Collision coverage will be measured similarly to a policy containing only one of the coverages for the purposes of this disclosure.

o Comparisons year over year within each company will be distorted when there are material changes in mix across these various types of exposures. Comparisons between companies could also be distorted. We recognize that this aggregated information is regularly used to compare premium but comparing average premiums could be distorted.

• Calendar date alignment—We note that the timing for the source of exposure data requested (that is available currently in company ratemaking systems) may not match the financial reporting data for financial premium. Exposures are typically maintained in detailed policy-based systems along with policy premium and are provided on a policy year basis. They are often separate from financial reporting systems where premium is on



Attachment P

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a calendar-year-earned basis. While premiums from ratemaking and financial systems could be reconciled, they might not provide a precise match. We note that data from ratemaking systems is already available and provided when requested by regulators or through specific data calls and filing inquiries.

• Existing alternative data sources—Some of the data requested is already available through statistical plan reporting which may meet the intended need. Statistical plan data is primarily available to regulators (the restricted availability is intended to protect the proprietary nature of each company’s data).

Changes that COPLFR would suggest that would improve the proposal (2021-11BWG):

• Include a complete and clear definition of exposure and calculation for each line proposed, particularly as respects the crossing (or overlap) of calendar time periods. Clear specifications ensure greater consistency across companies reporting.

• Definitions that account or minimize distortions from mix would be recommended.

2021-13-BWG

• Granularity and definition—The (29) proposed components of additional reporting for Other Liability will require clear definition (or instruction) on how to map class plan or package policies to these new required sublines of Other Liability. Significant judgment will be necessary at the individual company level depending on the policies written by that company. It is not clear that the proposed sublines are exclusively defined to eliminate overlap, nor that they will subsequently add up to the whole (e.g., internet liability vs cyber; employee benefit liability vs. fiduciary; one package policy covering three sublines of liability). A particular policy type could possibly be matched to one reporting line or another, generating inconsistency across companies, or year after year as policy changes evolve or new products are distributed. It is not clear why more granularity of data would not be put into the statistical data requirements, rather than being added into the Annual Statement. The proposal notes an additional Appendix defining the 29 granular pieces, but we do not find those proposed components included in the exposure draft for review.

• Credibility/Quality (IBNR)—We note that further subdividing the Liability data, already sparse in areas, will not necessarily provide valuable additional information across all the data elements requested. Inclusion of Incurred But Not Reported (IBNR) reserves at this new granular level of detail will most likely be arrived at through a company-determined allocation process. Liability is generally a low frequency / high severity line of business. Actuarial reserves for Liability are necessarily analyzed at higher levels of aggregated data to arrive at meaningful estimates and to reduce volatility in those reserve estimates over time. While some companies may segment Liability into credible pieces given their business profile, likely no company utilizes the (29) sublines proposed in their derivation of IBNR reserves.

• Inconsistency with the underlying policies—We find that this breakout of a broad type/cause of loss product such as Liability would be excessive and also is not consistent



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with the purpose of the General Liability policy, which is to provide broader aggregated coverage across a variety of situations which by themselves may not be as easily or affordably insurable.

• Preparation—The proposed breakouts of Other Liability as currently listed as the sublines requested would not be consistently defined across companies. If this list will continue to change, it should be noted that the value and quality of the information would be reduced with each change, and each change would require additional company preparation time as well as discretion to report. Given appropriate time to prepare systems for this change, the quality of the data would improve.

Changes that COPLFR would suggest that would improve the proposal (2021-13-BWG):

• Remove the requirement to include IBNR reserves from this new granular level of Liability reporting.

• Clearly define the sublines and eliminate any overlap or redundancies. Balance the additional information requested with the value added by collecting that additional granularity. For example, what is the difference between cyber and internet liability? Where would you categorize a package Liability policy that provides coverage across three of the above proposed sublines?

• Please provide and expose for comment the Appendix noted in the proposal that clearly defines the lines and coverages requested.

COPLFR appreciates this opportunity to provide comments to the NAIC Blanks Working Group. We hope these observations are helpful, and we welcome further discussion. If you have any questions about our comments, please contact Rob Fischer, the Academy’s casualty policy analyst, at [email protected].

Sincerely,

Derek Freihaut, MAAA, FCAS Chairperson Committee on Property and Liability Financial Reporting American Academy of Actuaries



Attachment P

Comments of the Center or Economic Justice

To the NAIC Blanks Working Group

In Support of Proposal 2021-11BWG

October 22, 2021

CEJ offers the following comments in support of Proposal 2021-11BWG.

Proposal 2021-11BWG was revised to reflect earlier substantive comments and then re- exposed to offer interested parties, CASTF and other regulators the opportunity to offer additional comments. The Blanks WG asked CASTF for additional questions, concerns or comments.

Our comments in support of the proposal are summarized as follows. More detailed discussion of some of the points follow the summary.

1. The addition of two data elements – written exposures and earned exposures – to the current reporting of written premium and earned premium for the private passenger auto and homeowners lines of business will provide useful and relevant information for regulators, policymakers and the public by providing new company-specific information for financial and market analysis as well as facilitating the calculation of average premium for personal auto and homeowners insurance in a time frame to make those calculations meaningful and less deceptive than current NAIC report time frames.

2. 2021-11BWG is consistent with and furthers the goals articulated in the NAIC State

Ahead strategy.

3. While the Blanks request to CASTF was broad in scope, CASTF has lost focus. As it is unclear what feedback CASTF or CASTF members will be providing, it is not possible in these comments to provide a complete response. However, it is clear that, instead of simply answering the questions whether 2021-11BWG has any technical problems or conflicts with existing CASTF reports – the answer is no to both questions – CASTF decided to pursue “alternatives” to 2021-11BWG that, in fact, are not alternatives.

CEJ Comments to Blanks Working Group re Proposal 2021-11BWG Attachment P October 22, 2021 Page 2

4. The re-exposure of 2021-11BWG has given the industry more time to provide evidence for their opposition. Despite two CASTF meetings in which industry voiced their opposition, the arguments by industry are unsupported by evidence or logic and are easily shown to be false and without merit. Given the lack of any substance to the industry opposition, we are left to conclude that industry opposition is based simply on the fact that the proposal was offered by a consumer stakeholder.

5. The argument featured most prominently in industry’s opposition at the CASTF meetings

and in prior Blanks WG meetings is that the proposed data elements are “statistical” data, not financial data, and that the annual and quarterly financial statements are reserved only for financial data. Industry argues that including “statistical” data in financial statements will essentially lead to the end of civilization as we know it. One industry speaker at CASTF argued that “if it doesn’t have a dollar sign in front of it, it’s not financial data.” This industry argument, bordering on the nonsensical, is contradicted by evidence in several ways:

a. There are many pieces of information in the financial statements without a dollar

sign in front of them; b. There are numerous schedules in the financial statements that are used for

purposes other than financial analysis; c. The new data elements are financial information produced from the same sales

transaction data that insurers use to calculate written and earned premium.

6. Contrary to industry claims, the additional data elements in 2021-11BWG – and average premium calculations generated – will not be misleading to regulators, policymakers or the public. The proposal requires the reporting of two data elements, not the publication of any calculations. The potential average premium calculations mirror those in CASTF reports, but would be available, much sooner.

7. The additional data elements both complement CASTF’s statistical reports and provide

additional information not available in the CASTF statistical reports. The so-called alternative that some members of CASTF are promoting – speeding up the premium and exposure portion of statistical reporting to generate a portion of the CASTF reports hopefully one year after the end of the experience year instead of two years – is not actually an alternative:


a. There is no company-specific information in the statistical reports, rendering the

current or “speeded-up” partial CASTF reports useless for financial or market analyses.

b. There is no quarterly reporting. c. The production of the more limited information remains far slower than would

occur with 2021-BWG.

8. The concerns about “data quality” are not supported by evidence or logic. Industry argues that the statistical reports submitted by states and statistical agents to CASTF for compilation into the annual CASTF auto and home reports undergo significant data quality review that would not occur with 2021-11BWG. The arguments are misplaced for several reasons.

a. The comparison of reporting earned exposures and written exposures by state or

countrywide is not comparable to the level of detail in the statistical reports reviewed by statistical agents. For those statistical agents that only collect summary data from insurers, those data reports are broken down by detailed coverages or policy form number (three or four times as many coverages as lines of business), by geographic territory (county, rating territory or zip code), by voluntary versus assigned risk markets and, for auto, by minimum limits versus increased limits. There is a qualitative and quantitative difference is data quality for summary reports with this many reporting cells per state than data quality for two data elements per state per annual statement line of business.

b. The calculation of the two new data elements is done in precisely the manner that

written premium and earned premium are calculated and reported by insurers. If insurers are unable to accurately calculate written premium, earned premium, written exposures and earned exposures by state by line of business – data elements that are literally the core of any insurance business operation – the integrity of the entire data reporting system is put into question.

c. One or more of the statistical agents, in response to the CASTF survey, indicated

that their data quality review included reconciliation to insurers’ NAIC financial statements. The fact that these statistical agents utilize financial statements for data quality review and reconciliation provides evidence of the reliability of these top line numbers reported in the financial statements.


9. There will be a non-material cost burden on insurers to report the additional data

elements. Again, the CASTF survey of statistical agents provided evidence that the new data elements can be easily calculated. In reality, we know that these data elements are already being calculated and used by insurers because the data elements are found in insurer rate filings.

10. Contrary to industry claims, there is no basis to argue that the by-company written and

earned exposures are trade secrets or proprietary commercial information. Here again, industry has made an assertion without any evidence or logic. The premise behind a trade secret claim is that public release of the information would place that company at a competitive disadvantage or cause the company to lose a competitive advantage. This is clearly not the case with annual reporting of written and earned exposures by state for the auto and home lines of business or quarterly reporting on a countrywide basis.

a. Written or earned exposures or both are routinely found in insurer rate filings that

are public information.

b. The data elements do not provide information that would enable one insurer to gain a competitive advantage on another or lose a competitive advantage on another. Insurers currently engage in real-time business intelligence, monitoring competitors’ rate filings so they can see – in real time – how their rates compare to any one or more competitors at a granular geographic level, a granular set of rating characteristics and a granular set of coverages. The proposed data elements are state-wide, aggregated at the annual statement line of business, precluding any type of granular analysis by one insurer of another’s “strategy.” No insurer would wait until four months after the end of the experience period for such aggregate data to respond to significant rate changes or other competitive challenges that occurred a year earlier.

2021-11BWG is consistent with and furthers the goals articulated in the NAIC State Ahead strategy.

The State Ahead Strategic Plan includes the following:

Optimize the NAIC’s world-class financial data and information for regulator-focused analytics, including predictive analytical tools

Optimizing financial data includes modernizing the way the data is organized to make it more consumable for state insurance regulators, staff, industry and the public.


A goal of State Ahead as well as other NAIC IT initiatives is to overcome the limitations

of data silos and move to data warehouses / data lakes that permit more useful and usable analysis. By leveraging the core resource of the NAIC – the financial statement reporting infrastructure -- 2021-11BWG is consistent with and furthers these goals. It represents the most efficient – least cost approach – and consistent method for collecting information to improve financial and market analysis and to provide policymakers and the public with important information in a timely fashion.

Use and Value of 2021-11BWG to Financial Analysts, Market Analysts, Policymakers and the Public

The addition of two data elements – written exposures and earned exposures – to the current reporting of written premium and earned premium for the private passenger auto and homeowners lines of business will provide useful and relevant information for regulators, policymakers and the public by providing some of the same information in current CASTF reports but two or more years earlier.

But 2021-11BWG provides different information that creates greater usefulness for financial and market analysts – namely, company-specific information not found in the CASTF reports. By providing exposure counts to complement the current premium reporting, analysts can better assess what is driving changes in written premium – changes in rates or changes in exposures. An increase in premium associated with an increase in exposures tells a different story than an increase in premium associated with a decrease in exposures, particularly if such company-specific experience is different from industry experience. Such analysis is particularly relevant for both the personal auto and homeowners lines because of the impact of major catastrophes on insurers’ risk management and pricing decisions.

Regarding the average premium calculations, the NAIC and individual states have determined that average personal auto premium and average homeowners premium are relevant and useful information for regulators, policymakers and the public, as evidenced by the publication of these values in the Auto Insurance Database Report and the Dwelling, Fire, Homeowners Owner-Occupied, and Homeowners Tenant and Condominium/Cooperative Unit Owner’s Insurance Report.

For example, on page 3 of the 2021 Auto Insurance Database Report, the average expenditure calculation is shown as total personal auto written premium divided by liability written exposures. This calculation can be exactly replicated with the data reported pursuant to 2021-11BWG – nearly two years sooner than the publication of the Auto Insurance Database Report.


Similarly, the average premium in the Homeowners report is calculated by dividing

written premium by written exposures. Written exposures are expressed as house-years. The report includes a table aggregating written exposures by homeowners owner-occupied and homeowners tenants and condo/co-op. The report calculates total average premium by dividing written premium by written exposures for homeowners owner-occupied policy forms and for tenant/condo/coop policy forms. 2021-11BWG allows exact replication of the tenant/condo/coop calculation while permitting an owner-occupied calculation limited to homeowners policy forms – nearly two years sooner than the publication of the Homeowners report.

If the publication of average premium for personal auto and residential property insurance is sufficiently relevant and important for the NAIC to publish these values, it is equally or more relevant and important to provide data permitting these calculations in a far more timely manner.

Contrary to industry claims, the additional data elements – and average premium calculations generated – will not be misleading to regulators, policymakers or the public.

Some have argued that average premium calculations developed from data reported pursuant to 2021-11BWG would be misleading or confusing to consumers. This argument is logically and factually incorrect.

First, if the potential calculations with data reported pursuant to 2021-11BWG replicate calculations in the CASTF reports, it simply can’t be argued that the average premium values are misleading. In fact, by making an average premium value available much closer to the experience period, the average premium calculations generated from data reported pursuant to 2021-11BWG are more relevant and less misleading that values reported two years after the experience period.

For example, the NAIC issued a press release on March 9, 2021 announcing the release of the Auto Insurance Database Report. The release stated, “The national average annual expense per insured vehicle was $1,190 in 2018, a 20.87% increase from 2014.” When newspapers pick up this story, there is no caveat that the data are two to three years old and may not reflect current conditions. Rather, the logical response from media and consumers is that this information is relevant and current. By permitting the calculation of average premium values two years earlier than the CASTF reports, 2021-11BWG will reduce confusion and the potential for policymakers and consumers to be misled.


Second, some have argued that the CASTF reports are not misleading or confusing

because the reports provide more detail and explanation about the tables in the reports. The additional data detail is important and useful for some purposes, but the fact remains that NAIC and state insurance department press releases and media coverage focus on the top line numbers, not the detailed analyses. Stated differently, providing a report with more detail and commentary is no guarantee that the detailed data or commentary will be used or relied upon.

Third, if confusion or misconception are a concern, there is nothing to prevent the NAIC – or state insurance departments – from issuing a press release or brief report with any caveats or commentary shortly after the 2021-11BWG data are reported.

Fourth, denying the collection and reporting of the additional data elements in 2021- 11BWG based on false claims about misleading and confusing policymakers and consumers is simply censorship based on the implicit assumption that only insurers and regulators know how to analyze and present insurers’’ financial information. This implicit assumption is forcefully disproved by the presence of scores of rating agencies, financial market analysis and academics who analyze and interpret insurers’ financial information.

The additional data elements are financial information suited to reporting through the annual and quarterly financial statements – comprehensive, uniform

Industry has incorrectly argued that the two additional data elements in 2021-11BWG are statistical data and not financial data and, consequently, do not belong in the quarterly and annual financial statements.

As evidenced by the recent efforts by the Statistical Working Group to explore the potential for timelier reporting by statistical agents of premium and exposure data, the defining characteristic of statistical reports is the provision of claims experience matched to exposures. It is this matching that requires statistical agents to wait 15 months after the end of the experience period to collect claims experience associated with exposures from that experience period.

In contrast written and earned premium and written and earned exposures are financial information available immediately after the end of the experience period. To understand why this is the case, consider how insurers calculate the written and earned premium values reported in the annual and quarterly financial statements.


Insurers maintain a database of sales transactions – records of when a new or renewal

policy was issued and the amount of premium associated with that policy. When the insurer calculates written premium for an experience period, the insurer sums the premium on policies issued during the period and nets out return premium for net written premium during the period. When the insurer calculates the earned premium for the period, the insurer calculates the portion of the policy term occurring during the experience period, multiples this fraction times the policy premium and sums these amounts.

The calculation of written exposures and earned exposures is identical to the calculation of written and earned premium with the exception that instead of summing premium, the calculation sums vehicles insured and homes insured, respectively, for personal auto and homeowners. No claims information is involved and the same financial records used to calculated written and earned premium are used to calculate written and earned exposures.

Again, the CASTF survey of statistical agents confirmed this analysis. One statistical agent, ISO, indicated they could provide the requested premium and exposure data 5 months after the end of the experience year. Why? Companies reporting to ISO, which represents about 35% to 40% of the personal auto and homeowners markets, report transaction-detail data (as opposed to data summarized by coverage, rating territory, voluntary vs. assigned risk market). ISO collects data similar to the way that insurers maintain their data – as a series of sales and claims transactions with policyholders and claimants. ISO’s ability to produce the premium and exposure data just five months after the experience year confirms that insurers, who have the original data, can – and routinely do – promptly calculate the written and earned exposure data following the end of the experience period.

Finally, a list of a few of the of the items reported in the financial statements that either “do not have a dollar sign in front of them” or are included for purposes other than financial analysis and solvency review:

• Credit Insurance Experience Exhibit – not used for solvency analysis, includes written and earned exposures for credit property

• Private Flood Insurance Supplement – not used for solvency analysis, includes policy counts and number of claims

• Cybersecurity and Identify Theft Insurance Coverage supplement – not used for solvency analysis, includes policy-in-force counts and number of claims

• Bail Bond Supplement – not used for solvency analysis • Supplemental Compensation Exhibit -- not used for solvency analysis • Accident and Health Policy Experience Exhibit – includes number of policies or

certificates and number of covered lives and member months.


• Schedule T Interstate Compact Exhibit of Premiums Written – not used for solvency

analysis • Schedule P Parts 4A and 5B – includes several sections for the number of claims for

homeowners and personal auto liability, respectively

By virtue of financial statement reporting, 2021-11BWG includes some data quality checks.

The instructions for reporting included 2021-11BWG require that the earned premium and written premium values tie to other exhibits in the annual and quarterly financial statements. These are core financial data points that, themselves, are typically used to verify and reconcile other data reports. For example, the statistical agent AAIA, in its response to the Statistical Working Group, states, “As far as how soon AAIS could get this data to the NAIC, our initial assessment is that if we started on the reconciliation when we get the preliminary annual statement data in May we should be able to finalize data by September.”

There will be a non-material cost burden on insurers to report the additional data elements.

Some have raised the argument that reporting of data pursuant to 2021-11BWG will be costly for insurers, although this claim of cost burden has not been supported by any evidence or logical explanation. In fact, it is demonstrable that any additional cost to insurers will be non-material.

Recall the discussion above about how insurers track sales transactions and calculate written and earned premium for financial statement reporting. With access to the transaction data that permits calculating written and earned premium, the analogous calculations of written and earned exposures are minor additions. This ease of calculation is evidenced by the response of ISO to the Statistical Working Group inquiry. Insurers reporting to ISO report transaction-detail data – similar to the data records maintained by insurers. By virtue of having transaction data, indicated the ability to report the premium and exposure data shortly after receipt from insurers.

2021-11BWG does not require insurers to collect any new data elements nor even to calculate new data elements. It simply asks insurers to report written and earned exposures at the same time and in the dame detail and written and earned premiums are reported in financial statements.

Attachment P

1

Oct. 22, 2021 Survey Response to Blanks (E ) Working Group

Blanks Proposal 2021-11BWG Support the proposal: 9.5 states*

SUPPORT OPTIONS

State # CA CO CT* MN NC NH NM NV OR VT

Support as is X X X X X X Support all except quarterly reporting X X X X X X X Support but list caveats (such as those listed in statistical reporting)

X X X X X X X

Neutral; just list issues X Oppose the proposal: 11.5 states*

Neutral; just list issues: 9 states

NEUTRAL OPTIONS CT NJ AZ IA KS ME PA TX WA Support or Neutral (also included above) X Oppose or Neutral (also included above) X X Neutral Only X X X X X X X

*CT voted for option under “Support” and under “Oppose.” To avoid double counting, we used a vote of 0.5 for each option. Received one survey from New York, an interested regulator, who favored support of the proposal, options b and c (no quarterly and list caveats). This survey response is not included in the tabulations above.

OPPOSE OPTIONS CT* DC IL LA MO MT NC ND NJ OH SC WV

Oppose, No reason provided X Cost outweighs the benefit X X X X X X It is a stretch to call this solvency data and the financial statement is intended to collect solvency-related data.

X X X X X X X X X

This is a slippery slope to introduce data that is more applicable to market analysis in a solvency-focused financial statement.

X X X X X X X X X

We can get statistical data at an aggregate level (with some limitations) from statistical agents.

X X X X X

This type of data company by company (vs. in aggregate) can be materially inaccurate (we have to correct data submitted to us by companies when we do statistical reports).

X X X X X

The potential for misuse of this data is too high.

X X X X X X

Neutral; just list issues X X

Attachment P

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Blanks Proposal 2021-11BWG

ADDITIONAL COMMENTS:

CA: While Annual Statements are primarily used in solvency monitoring, they have evolved in a manner that allows for their use in other efforts. Annual Statement data is used as a point of reconciliation in the review of rate filings. In California, our first step in rate filing review is to ensure that the data underlying rate filings is consistent with externally reported (i.e., Annual Statement) data. We can do that currently with premiums and, to some extent, losses, but not exposures. The inclusion of exposure data in the Annual Statement will give us that missing piece, or something close to it, to reconcile to. Furthermore, we don't consider this information proprietary. We require that companies divulge not only high-level exposure data but also much more granular cuts of their exposure data for purposes of rate filings, including dislocation exhibits and other filing support, and that data is submitted publicly via SERFF.

CT: This is a temporary solution. The Statistical Data WG can enhance and provide timely report with better quality, and NAIC should take a long-term solution for a better stat reporting for future needs in AI, etc. CT would like to work on that.

IL: To my knowledge, the Blanks WG asked the CASTF for technical review and comment, I offer the following

additional consideration: the cost benefit analysis should be considered. Not enough was done here to analyze this.

KS: To my knowledge, the Blank WG's proposal was sent to CASTF for "review and comment". I believe that this

sort of ask would not warrant a CASTF vote for or against the proposal, but instead it would warrant a list of concerns/comments that have been voiced during CASTF's review to be provided to the Blanks WG.

MO: 1) There is a risk that the average premium by legal entity calculated from the exposure data could be used

in a misleading way. Average premium for a legal entity can change even if no policyholders experienced a change in premium. For example, a group may decide to renew higher amount of insurance homeowners policies in one legal entity and lower amount of insurance policies in another legal entity. This would cause average premium for both legal entities to change, even if there was no change in any individual policyholder's premium. It would be incorrect to conclude from the average premium changes that there had been a change in any individual policyholder's premium.

2) We have not heard how regulators would use this information. We have also not heard from companies regarding how much this might cost.

3) Regulators can already request exposure information from an entity if the regulator has a solvency concern. Our state has done this in the past.

4) Exposures by state by legal entity could be considered confidential, competitive information protected under trade secret statutes. The current auto and homeowners reports promulgated by the NAIC get around this issue because the information is aggregated across companies, not provided by individual legal entity. It is not necessarily true that exposure information is already provided in public SERFF filings.

Attachment P

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Blanks Proposal 2021-11BWG

NC: 1) Exposure data of value for a wide range of regulatory studies, including but not limited to, solvency 2) we need a consistent definition of exposure. For some lines, AOI (amount of insurance) is best 3) the data aggregated from individual insurers will not match data from stat agents 7 others 4) data from individual insurers will require way more reasonability tests & resources from NAIC staff.

NM: I think exposure reports on an annual basis could be useful in general and applicable in solvency

monitoring, but an accompanying explanatory disclosure may be necessary to explain any nuance (like sharp changes in exposure, etc.)

NV: Whatever the concerns that some have raised with this proposal, the benefit of having more timely

exposure data is overwhelming. As such, the delay of 2+ years renders the data of extremely limited value when reflecting and responding to time-sensitive circumstances, such as the ever-evolving COVID-19 pandemic, and such rapid changes of external market conditions are going to be a "new normal" going forward and not a temporary anomaly.

OH: The proposal does not appear to add value for financial reporting. We have a tool to review Statistical

reporting. It is unfortunate that this report is not as timely as we would like, but I believe we can update those procedures to provide the reports in a more timely manner.

SC: Mr Birnbaum attempted to sell this Task Force on supporting his proposal by insisting that these items would be useful for us for solvency monitoring, market analysis, and rate regulation. Mr Chou of CT expressed concern that a true "cost-benefit" analysis was necessary. I agree with him, and I'm hopeful that the industry will weigh in on the expected costs. Maybe then, someone will actually enumerate some concrete benefits of the proposal. To date, I don't think that has been done, outside of a few "it would be nice to see" comments.

Attachment P

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Blanks Proposal 2021-11BWG Statistical Data Collection Alternative

The Statistical Data Working Group met on September 23rd and October 7th to discuss the charge from this Task Force that asked us to gather information on whether the timeline can be sped up on receipt of premium and exposure information from outside parties. NAIC staff asked submitting statistical agents and residual markets if their current timeline for submitting data could be sped up. NAIC staff also gathered data on what percentage of the total data each party was submitting.

We received varied responses from the submitting parties. Due to the fact that, currently, statistical agents are not collecting data in the same way, they cannot provide the data to the NAIC on the same timeline. Additionally, statistical agents indicated that not only do they need to wait for company submissions, but they also need time for data quality checks and communication with companies for any data issues.

HOMEOWNERS REPORT--For the Homeowners report, in the year following the data year, we would be able to collect 32% of premium data by the end of May, 60% of premium data by the end of August, and 99% of premium data by the end of November. We initially believed California would still only be able to provide their data every other year, but they have since indicated that they would be able to use another data set to send in average premium data, but not full premium and exposure data, in June of the year following the data year. All data would still need to be aggregated by NAIC staff, making any output report available in December following the data year (i.e. 2022 data available approx. Dec. 2023), at the earliest.

AUTO REPORT--For the auto report, in the year following the data year, we would be able to collect 32% of premium data by the end of May, 49% of premium data by the end of August, and 91% of premium data by the end of November. Texas data, which makes up the remaining 9% of data, would not be provided until January of the next year. Again, all data would have to be aggregated and reviewed by NAIC staff before a report could be produced (i.e. 2022 data available approx. Feb. 2024). The responses for the Auto report are based only on premium and exposure data. Loss data cannot be provided on this same timeline.

The Statistical Data Working Group has provided the necessary information requested by this task force. The Working Group is open to continuing the discussion of data collection, including discussion on the data collection and submission process outlined in the Statistical Handbook, that may address the need for more timely data.

blanks (e) working group roll call

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