Naic Blanks (E) Working Group

NAIC BLANKS (E) WORKING GROUP

Blanks Agenda Item Submission Form

FOR NAIC USE ONLY DATE: 02/08/2012 Agenda Item # 2012-22BWG Year 2012 CONTACT PERSON: Changes to Existing Reporting [ ] TELEPHONE: New Reporting Requirement [ X ]

EMAIL ADDRESS: REVIEWED FOR ACCOUNTING PRACTICES AND PROCEDURES IMPACT ON BEHALF OF: No Impact [ X ] Modifies Required Disclosure [ ] NAME: Michael Consedine & Steve Johnson DISPOSITION

TITLE: [ ] Rejected For Public Comment [ ] Referred To Another NAIC Group AFFILIATION: Pennsylvania Insurance Department [ X ] Received For Public Comment [ ] Adopted Date ADDRESS: 1345 Strawberry Sq. [ ] Rejected Date [ ] Deferred Date Harrisburg, PA 17120 [ ] Other (Specify)

BLANK(S) TO WHICH PROPOSAL APPLIES

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

[ ] Life and Accident & Health [ X ] Property/Casualty [ ] Health [ ] Separate Accounts [ ] Fraternal [ ] Title [ ] Other Specify

Anticipated Effective Date: Annual 2012

IDENTIFICATION OF ITEM(S) TO CHANGE

See details on next page.

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

See details on next page.

NAIC STAFF COMMENTS

Comment on Effective Reporting Date:

Other Comments:

Add instruction for Certified Reinsurer Identification Number to Schedule F General Instructions

Add line number categories for certified reinsures to Schedule F, Part 3 and Part 4 remaining lines will be renumbered.

Add new Schedule F, Part 6, Sections 1 and 2 to the blank and instructions.

Renumber Schedule F, Part 6 to Part 7

Add inset to annual and quarterly liability page for certified reinsures for Line 16 also modify the instructions for that line.

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

In 2011, the NAIC adopted revisions to the Credit for Reinsurance Model Law (#785) and Credit for Reinsurance Model Regulation (#786). These model revisions will act to reduce reinsurance collateral requirements for non-U.S. reinsurers meeting certain criteria for financial strength and business practices that are domiciled in qualified jurisdictions. Under the revisions, credit is allowed a domestic ceding insurer for reinsurance ceded to a new class of assuming insurers, certified reinsurers. As a result, it is necessary to consider revisions to the appropriate reinsurance schedules and instructions in order to collect the relevant information with respect to these reinsurance transactions.

SCHEDULE F

Index to Schedule F

Part 1 – Assumed Reinsurance Part 2 – Portfolio Reinsurance Part 3 – Ceded Reinsurance Part 4 – Aging of Ceded Reinsurance Part 5 – Provision for Unauthorized Reinsurance Part 6 – Provision for Reinsurance Ceded to Certified Reinsurers Part 67 – Provision for Overdue Authorized Reinsurance Part 78 – Provision for Overdue Reinsurance (Authorized Over 20%) Part 89 – Restatement of Balance Sheet to Identify Net Credit for Ceded Reinsurance

Due Date

All parts of Schedule F are to be filed with the annual statement.

Please note that Parts 1, 3, 4, and 5 and 6 of this schedule are reported with thousands omitted. Parts 2, 67, 78 and 89 are reported in whole dollars.

Detail Eliminated To Conserve Space

Certified Reinsurer Identification Number

In order to report transactions involving certified reinsurers correctly, the appropriate Certified Reinsurer Identification Number (CRIN) must be included on Schedule F instead of the FEIN. The CRIN is assigned by the NAIC and is listed in the NAIC Listing of Companies. If a certified reinsurer does not appear in that publication, an application for a number should be filed with the NAIC Financial Systems and Services Department, Company Demographics Analyst. The application must be submitted along with a copy of the license or other document issued by the company’s domiciliary regulator authorizing it to transact insurance or reinsurance business, and a copy of the certification issued by the reporting entity’s domiciliary state. Documents submitted in a language other than English must be accompanied by an English Translation.

Once a number has been assigned, the applying company will be advised so that its Schedule F may be completed or corrected. Newly assigned numbers are incorporated in revised editions of the NAIC Listing of Companies, which are available semi-annually. The NAIC also provides this information to annual statement software vendors for incorporation into the software.

Determination of Authorized Status

The determination of the authorized, or unauthorized or certified status of an insurer or reinsurer listed in any part of Schedule F shall be based on the status of that insurer or reinsurer in the reporting entity’s state of domicile.

CEDED REINSURANCE AS OF DECEMBER 31, CURRENT YEAR

Group or Category Line Number

Total Authorized Affiliates U.S. Intercompany Pooling...... 0199999 U.S. Non-Pool...... 0299999 Other (Non-U.S.)...... 0399999 Total Authorized – Affiliates...... 0499999 Other U. S. Unaffiliated Insurers (Under $100,000)...... 0599998 Other U.S. Unaffiliated Insurers...... 0599999 Pools Mandatory Pools* @...... 0699999 Voluntary Pools* %...... 0799999 Other Non-U.S. Insurers # (Under $100,000)...... 0899998 Other Non-U.S. Insurers#...... 0899999 Total Authorized...... 0999999 Total Unauthorized Affiliates U.S. Intercompany Pooling...... 1099999 U.S. Non-Pool...... 1199999 Other (Non-U.S.)...... 1299999 Total Unauthorized – Affiliates...... 1399999 Other U.S. Unaffiliated Insurers (Under $100,000)...... 1499998 Other U.S. Unaffiliated Insurers...... 1499999 Pools Mandatory Pools* @...... 1599999 Voluntary Pools* %...... 1699999 Other non-U.S. Insurers # (under $100,000)...... 1799998 Other Non-U.S. Insurers#...... 1799999 Total Unauthorized...... 1899999 Total Certified Affiliates U.S. Intercompany Pooling ...... 1999999 U.S. Non-Pool ...... 2099999 Other (Non-U.S.) ...... 2199999 Total Unauthorized – Affiliates ...... 2299999 Other U.S. Unaffiliated Insurers (Under $100,000) ...... 2399998 Other U.S. Unaffiliated Insurers ...... 2399999 Pools Mandatory Pools* @ ...... 2499999 Voluntary Pools* % ...... 2599999 Other non-U.S. Insurers # (under $100,000) ...... 2699998 Other Non-U.S. Insurers# ...... 2699999 Total Certified ...... 2799999 Total Authorized, and Unauthorized and Certified...... 192899999 Total Protected Cells...... 202999999 Totals...... 9999999

AGING OF CEDED REINSURANCE AS OF DECEMBER 31, CURRENT YEAR

Include in this schedule only companies for which balances are shown in Schedule F, Part 3, Columns 7 and/or 8.

If a reporting entity has amounts reported for any of the following required groups, categories, or subcategories, it shall report the subtotal amount of the corresponding group, category, or subcategory, with the specified subtotal line number appearing in the same manner and location as the preprinted total or grand total line and number:

Total Authorized Affiliates U.S. Intercompany Pooling...... 0199999 U.S. Non-Pool...... 0299999 Other (Non-U.S.)...... 0399999 Total Authorized – Affiliates...... 0499999 Other U.S. Unaffiliated Insurers...... 0599999 Pools Mandatory Pools*...... 0699999 Voluntary Pools*...... 0799999 Other Non-U.S. Insurers#...... 0899999 Total Authorized...... 0999999 Total Unauthorized Affiliates U.S. Intercompany Pooling...... 1099999 U.S. Non-Pool...... 1199999 Other (Non-U.S.)...... 1299999 Total Unauthorized – Affiliates...... 1399999 Other U.S. Unaffiliated Insurers...... 1499999 Pools Mandatory Pools*...... 1599999 Voluntary Pools*...... 1699999 Other Non-U.S. Insurers#...... 1799999 Total Unauthorized...... 1899999 Total Certified Affiliates U.S. Intercompany Pooling ...... 2099999 U.S. Non-Pool ...... 2199999 Other (Non-U.S.) ...... 2299999 Total Unauthorized – Affiliates ...... 2399999 Other U.S. Unaffiliated Insurers ...... 2499999 Pools Mandatory Pools* ...... 2599999 Voluntary Pools* ...... 2699999 Other Non-U.S. Insurers# ...... 2799999 Total Certified ...... 2899999 Total Authorized, and Unauthorized and Certified...... 12999999 Total Protected Cells...... 23099999 Totals...... 9999999

* Pools and Associations consisting of affiliated companies should be listed by individual company names.

# Alien Pools and Associations should be reported on Schedule F under the category “Other Non-U.S. Insurers.”

PROVISION FOR REINSURANCE CEDED TO CERTIFIED REINSURERS AS OF DECEMBER 31, CURRENT YEAR

Total Affiliates U.S. Intercompany Pooling ...... 0199999 U.S. Non-Pool ...... 0299999 Other Non-U.S. Insurers# ...... 0399999 Total Affiliates ...... 0499999 Total Other U.S. Unaffiliated Insurers ...... 0599999 Total Pools and Associations Mandatory* ...... 0699999 Voluntary* ...... 0799999 Total Other Non-U.S. Insurers# ...... 0899999 Total Affiliates and Others ...... 0999999 Total Protected Cells ...... 1099999 Totals ...... 9999999

* Pools and Associations consisting of affiliated companies should be listed by individual company names. # Alien Pools and Associations should be reported on Schedule F under the category “Other Non-U.S. Insurers.

Column 5 Certified Reinsurer Rating (1 through 6)

Report the certified reinsurer’s rating as assigned by the ceding insurer’s domiciliary state.

Column 6 Effective Date of Certified Reinsurer Rating

Report the effective date of the certified reinsurer’s rating that is applicable to the reinsurance recoverable reported on the individual line. [Note on multiple ratings/downgrades/upgrades/etc?]

Column 7 Percent Collateral Required for Full Credit (0% - 100%)

Report the percentage of collateral that is required to be provided by the certified reinsurer, in accordance with the rating assigned by the ceding insurer’s domiciliary state in order for a domestic ceding insurer to receive full financial statement credit for the reinsurance ceded to the certified reinsurer, that is applicable to the reinsurance recoverable reported on the individual line.

Column 8 Net Amount Recoverable from Reinsurers (Sch. F Part 3 Col. 18)

Net Amount Recoverable from Reinsurers; Part 3, Column 18 by individual certified reinsurer. Note that this amount is the Total Amount Recoverable from Reinsurers minus Miscellaneous Balances payable to the reinsurer.

Report the amount of reinsurance recoverable from the certified reinsurer with respect to catastrophe losses that are subject to any collateral deferral period allowed under the state’s credit for reinsurance law and/or regulation.

Column 10 Net Recoverables Subject to Collateral Requirements for Full Credit

Net Recoverables Subject to Collateral Requirements for Full Credit (Column 8 minus Column 9)

Column 11 Dollar Amount of Collateral Required

Report the amount of collateral that is required in order for the reporting company to receive full financial statement credit for reinsurance. (Column 10 times Column 7)

Column 12 Multiple Beneficiary Trust

If the certified reinsurer utilizes a multiple beneficiary trust account for the purposes of meeting its collateral requirements as a certified reinsurer to U.S. ceding insurers, report the amounts within such trust that are applicable to the reporting entity’s reinsurance ceded to the certified reinsurer.

Column 13 – Funds Held by Company Under Reinsurance Treaties

Should agree with unauthorized portion of Schedule F, Part 3, Column 19.

Column 14 – Letters of Credit

Report the dollar amount of Letters of Credit provided by the certified reinsurer and held by or on behalf of the reporting entity as security for the certified reinsurer’s reinsurance obligations.

Column 15 – Letter of Credit Issuing or Confirming Bank American Bankers Association (ABA) Routing Number

Provide the issuing or confirming bank’s nine digit American Bankers Association (ABA) routing number.

For Fronted Letters of Credit, where a single bank issues a letter of credit as the fronting bank and sells to other banks undivided interests in its obligations under the credit, list the fronting bank but not the other banks participating.

For Syndicated Letters of Credit, where one bank acts as agent for a group of banks issuing the letter of credit but each participating bank is severally, not jointly, liable, leave column blank. Provide the ABA routing number for all banks in the syndicate in footnote (a).

For reinsurers providing letters of credit from multiple banks that are not part of a syndicated letter of credit, leave the column blank. Provide the ABA routing number for all of the banks in footnote (a).

The ABA routing number can be found at the following Web address:

http://abanumberlookup.com/#search

Column 16 – Letter of Credit Code

Enter “1” for single letter of credit that is not a syndicated letter of credit. Enter “2” for syndicated letter of credit. Enter “3” for multiple letters of credit. Leave blank when no letter of credit exists

Provide the name of the issuing or confirming banks whose ABA routing number was provided in Column 8. The name should be as shown as found on the following Web address:

http://abanumberlookup.com/#search

For Syndicated Letters of Credit, where one bank acts as agent for a group of banks issuing the letter of credit but each participating bank is severally, not jointly, liable, enter a reference code number in this column (e.g., 0001, 0002, etc.). Provide the name of each bank in the syndicate in footnote (a).

For reinsurers providing letters of credit from multiple banks that are not part of a syndicated letter of credit ,enter a reference code number in this column (e.g., 0001, 0002, etc.). Provide the name of each bank in footnote (a).

Column 18 – Other Allowable Collateral

Report trust funds, other than those held in a multiple beneficiary trust that are reported in Column 12, and other acceptable security.

Column 20 Percent of Collateral Provided for Net Recoverables Subject to Collateral Requirements

Report the percent of collateral provided by the certified reinsurer for net recoverables subject to collateral requirements. (Column 19 divided by Column 10)

Column 21 Percent Credit Allowed on Net Recoverables Subject to Collateral Requirements

Report the percent credit allowed on net recoverables subject to collateral requirements based on the amount of collateral provided by the certified reinsurer as compared to the amount of collateral that is required to be provided based on its assigned rating. (Column 20 divided by Column 7, not to exceed 100%))

Column 22 Amount of Credit Allowed for Net Recoverables

Report the amount of credit for reinsurance allowed for net recoverables based on the proportion of the collateral requirement that has been met by the certified reinsurer. (Column 9 + (Column 10 x Column 21)).

Column 23 Provision for Reinsurance with Certified Reinsurers Due to Collateral Deficiency

Provision for Reinsurance with Certified Reinsurers Due to Collateral Deficiency (Column 8 minus Column 22)

PROVISION FOR OVERDUE REINSURANCE CEDED TO CERTIFIED REINSURERS AS OF DECEMBER 31, CURRENT YEAR

Total Affiliates U.S. Intercompany Pooling ...... 0199999 U.S. Non-Pool ...... 0299999 Other Non-U.S. Insurers# ...... 0399999 Total Affiliates ...... 0499999 Total Other U.S. Unaffiliated Insurers ...... 0599999 Total Pools and Associations Mandatory* ...... 0699999 Voluntary* ...... 0799999 Total Other Non-U.S. Insurers# ...... 0899999 Total Affiliates and Others ...... 0999999 Total Protected Cells ...... 1099999 Totals ...... 9999999

* Pools and Associations consisting of affiliated companies should be listed by individual company names. # Alien Pools and Associations should be reported on Schedule F under the category “Other Non-U.S. Insurers.

Column 5 Reinsurance Recoverable on Paid Loss and LAE More Than 90 Days Overdue

Report the amount of reinsurance recoverable on paid losses and loss adjustment expenses that is more than 90 days past due.

Column 6 Total Reinsurance Recoverable on Paid Losses and LAE

Report the total amount of reinsurance recoverable on paid losses and loss adjustment expenses.

Column 7 Amounts Received Prior 90 Days

Report amount of reinsurance recoverable received in the past 90 days.

Column 8 Percent More Than 90 Days Overdue

Calculate the percent of reinsurance recoverable on paid losses and loss adjustment expenses that is more than 90 days past due. (Column 5 / (Column 6 + Column 7).

Column 9 If Col. 8 is less than 20%, report 20% of Amounts in Col. 5

If Column 8 is less than 20%, report 20% of amount in Column 5. If Column 8 is 20% or greater, report “0”.

If Column 8 is less than 20%, report 20% of amounts in dispute that are excluded from Column 5. If Column 8 is 20% or greater, report “0”.

Column 11 Amount of Credit Allowed for Net Recoverables

Report the amount of Net Credit Allowed (Schedule F Part 6 Section 1 Column 22).

Column 12 Total Collateral Provided

Report the total amount of collateral provided by the certified reinsurer (Schedule F Part 6 Section 1 Column 19).

Column 13 Total Unsecured Recoverable for which Credit is allowed

Report the total amount of unsecured reinsurance recoverable for which credit is allowed per Schedule F Part 6 Section 1 (Column 11 – Column 12).

Column 14 If Col. 8 is 20% or greater, report 20% x Col. 13

If Column 8 is 20% or greater, report 20% x amount reported in Column 13.

Column 15 Provision for Overdue Reinsurance Ceded to Certified Reinsurers

Provision for Overdue Reinsurance (Column 9 + Column 10 + Column 14, not to exceed Column 11).

SCHEDULE F – PART 6 7

PROVISION FOR OVERDUE AUTHORIZED REINSURANCE AS OF DECEMBER 31, CURRENT YEAR

PROVISION FOR OVERDUE REINSURANCE AS OF DECEMBER 31, CURRENT YEAR

SCHEDULE F – PART 8 9

RESTATEMENT OF BALANCE SHEET TO IDENTIFY NET CREDIT FOR REINSURANCE

LIABILITIES, SURPLUS AND OTHER FUNDS

Line 16 – Provision for Reinsurance

Should equal Schedule F, Part 79, Line 68.

SCHEDULE F – PART 6 – SECTION 1 Provision for Reinsurance Ceded to Certified Reinsurers as of December 31, Current Year (000 OMITTED)

1 2 3 4 5 6 7 8 9 10 11 Collateral Provided 20 21 22 23 Letter of Credit Issuing or 12 13 14 Confirming Bank 15 16 17 18 19 Percent of Collateral Percent Credit Provision for Provided for Allowed on Net Reinsurance Net Net Recoverables with Certified Percent Net Amount Recoverables Dollar American Total Recoverables Subject to Reinsurers Effective Collateral Recoverable Catastrophe Subject to Amount of Funds Held by Bankers Collateral Subject to Collateral Amount of Credit Due to Certified Date of Required from Recoverables Collateral Collateral Company Association Provided Collateral Requirements Allowed for Net Collateral Federal NAIC Reinsurer Certified for Full Reinsurers Qualifying for Requirements Required Multiple Under (ABA) Letter of Other (Col. 12 + Requirements (Col 20 / Col 7, Recoverables(Col. 9 Deficiency ID Company Name of Domiciliary Rating (1 Reinsurer Credit (0% (Sch. F Part 3 Collateral for Full Credit (Col 10 x Beneficiary Reinsurance Letters Routing Credit Bank Allowable 13 + 14 + (Col. 19 / by not to exceed + (Col. 10 x Col. (Col. 8 - Col. Number Code Reinsurer Jurisdiction through 6) Rating - 100%) Col. 18) Deferral (Col 8 - Col 9) Col 7) Trust Treaties of Credit Number Code Name Collateral 18 ) Col. 10) 100%) 21)) 22) 9999999 Totals XXX XXX XXX

SCHEDULE F – PART 6 – SECTION 2 Provision for Overdue Reinsurance Ceded to Certified Reinsurers

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Provision for Overdue Reinsurance If Col. 8 is less Ceded to Reinsurance than 20%, report Total Unsecured Certified Recoverable on Total Reinsurance 20% of Amounts Amount of Credit Recoverable for If Col. 8 is Reinsurers (Col. 9 Paid Loss and Recoverable on Amounts Percent More If Col. 8 is less than in Dispute Allowed for Net Total Collateral which Credit is 20% or greater, + Col. 10 + Col. Federal ID NAIC Name of Domiciliary LAE More Than Paid Losses and Received Prior Than 90 Days 20%, report 20% of Excluded from Recoverables (Sch. Provided (Sch. F allowed (Col. 11 - report 20% x 14) not to exceed Number Company Code Reinsurer Jurisdiction 90 Days Overdue LAE 90 Days Overdue Amounts in Col. 5 Col. 5 F Part 6 Col. 22) Part 6 Col. 19) Col. 12) Col. 13 Col. 11 9999999 Totals

1 2 3 4 5 6 7 8 9 10 11 Reinsurance Recoverable on Total Reinsurance Amounts in Col. 4 Amounts in Dispute Federal NAIC Paid Losses and LAE More Recoverable on Paid Amounts Col. 4 for Companies Excluded from Col. 4 for 20% Amount ID Company Than 90 Days Losses and Paid LAE Received Prior divided by Reporting less than Companies Reporting less of Amount in Reported in Col. 8 x Number Code Name of Reinsurer Overdue (a) (b) 90 Days (Cols. 5 + 6) 20% in Col. 7 than 20% in Col. 7 Col. 9 20% + Col. 10

SCHEDULE F – PART 78 Provision for Overdue Reinsurance as of December 31, Current Year

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

Federal NAIC Name Reinsurance Funds Held By Letters Ceded Other Other Sum of Cols. 5 Col 4 Greater of Col. 11 or ID Company of Recoverable Company Under of Balances Miscellaneous Allowed through 9 but not in minus Schedule F - Part 4 Number Code Reinsurer All Items Reinsurance Treaties Credit Payable Balances Offset Items Excess of Col. 4 Col. 10 Cols. 8 + 9

9999999 Totals 1. Total 2. Line 1 x .20 3. Schedule F-Part 6 7 Col. 11 4. Provision for Overdue Authorized Reinsurance (Lines 2 + 3) 5. Provision for Unauthorized Reinsurance (Schedule F-Part 5, Col. 20 x 1000) 6. Provision for Reinsurance Ceded to Certified Reinsurers (Schedule F-Part 6, Section 1, Col. 23 x 1000) 7. Provision for Overdue Reinsurance Ceded to Certified Reinsurers (Schedule 6, Section 1, Col 15 x 1000) 68. Provision for Reinsurance (sum Lines 4 + 5+ 6 + 7) (Enter this amount on Page 3, Line 16)

SCHEDULE F – PART 89 Restatement of Balance Sheet to Identify Net Credit for Reinsurance

1 2 3 As Reported Restatement Restated (Net of Ceded) Adjustments (Gross of Ceded)

LIABILITIES, SURPLUS AND OTHER FUNDS

1 2 Current Year Prior Year

1. Losses (Part 2A, Line 35, Column 8)...... 2. Reinsurance payable on paid losses and loss adjustment expenses (Schedule F, Part 1, Column 6)...... 3. Loss adjustment expenses (Part 2A, Line 35, Column 9)...... 4. Commissions payable, contingent commissions and other similar charges...... 5. Other expenses (excluding taxes, licenses and fees)...... 6. Taxes, licenses and fees (excluding federal and foreign income taxes)...... 7.1 Current federal and foreign income taxes (including $………. on realized capital gains (losses))...... 7.2 Net deferred tax liability...... 8. Borrowed money $………and interest thereon $...... 9. Unearned premiums (Part 1A, Line 38, Column 5) (after deducting unearned premiums for ceded reinsurance of $ ………..…..and including warranty reserves of $……………... and accrued accident and health experience rating refunds including $...... for medical loss ratio rebate per the Public Health Service Act)...... 10. Advance premium...... 11. Dividends declared and unpaid: 11.1 Stockholders...... 11.2 Policyholders...... 12. Ceded reinsurance premiums payable (net of ceding commissions)...... 13. Funds held by company under reinsurance treaties (Schedule F, Part 3, Column 19)...... 14. Amounts withheld or retained by company for account of others...... 15. Remittances and items not allocated...... 16. Provision for reinsurance (including ($...... certified) (Schedule F, Part 79)...... 17. Net adjustments in assets and liabilities due to foreign exchange rates...... 18. Drafts outstanding...... 19. Payable to parent, subsidiaries and affiliates...... 20. Derivatives ...... 21. Payable for securities...... 22. Payable for securities lending...... 23. Liability for amounts held under uninsured plans...... 24. Capital notes $………………..and interest thereon $………………...... 25. Aggregate write-ins for liabilities...... 26. Total liabilities excluding protected cell liabilities (Lines 1 through 25)...... 27. Protected cell liabilities...... 28. Total liabilities (Lines 26 and 27)...... 29. Aggregate write-ins for special surplus funds...... 30. Common capital stock...... 31. Preferred capital stock...... 32. Aggregate write-ins for other than special surplus funds...... 33. Surplus notes...... 34. Gross paid in and contributed surplus...... 35. Unassigned funds (surplus)...... 36. Less treasury stock, at cost: 36.1 ………….. shares common (value included in Line 30 $………………..)...... 36.2 ………….. shares preferred (value included in Line 31 $………………..)...... 37. Surplus as regards policyholders (Lines 29 to 35, less 36) (Page 4, Line 39)...... 38. Totals (Page 2, Line 28, Col. 3) DETAILS OF WRITE-INS 2501...... 2502...... 2503...... 2598. Summary of remaining write-ins for Line 25 from overflow page...... 2599. Totals (Lines 2501 through 2503 plus 2598) (Line 25 above) 2901...... 2902...... 2903...... 2998. Summary of remaining write-ins for Line 29 from overflow page......

2999. Totals (Lines 2901 through 2903 plus 2998) (Line 29 above) 3201...... 3202...... 3203...... 3298. Summary of remaining write-ins for Line 32 from overflow page...... 3299. Totals (Lines 3201 through 3203 plus 3298) ( Line 32 above)

DRAFTING NOTE: The quarterly Line 16 does not have Schedule F reference. That change does not apply to the quarterly statement changes.

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