Naic Blanks (E) Working Group - Blanks Agenda Submission Form

NAIC BLANKS (E) WORKING GROUPBlanks Agenda Item Submission FormFOR NAIC USE ONLY DATE: 02/03/2012 Agenda Item # 2012-18BWG Year 2012 CONTACT PERSON: Heather Davis Changes to Existing Reporting [ X ] TELEPHONE: 850-413-5070 New Reporting Requirement [ ] EMAIL ADDRESS: Heather. [email protected] REVIEWED FOR ACCOUNTING PRACTICES AND PROCEDURES IMPACT ON BEHALF OF: Florida Office of Insurance Regulation No Impact [ X ] Modifies Required Disclosure [ ] NAME: Toma Wilkerson DISPOSITIONTITLE: Director, Life & Health Financial Oversight [ ] Rejected For Public Comment [ ] Referred To Another NAIC Group AFFILIATION: [ X ] Received For Public Comment [ ] Adopted Date ADDRESS: 200 East Gaines Street [ ] Rejected Date [ ] Deferred Date Tallahassee, FL 32399-0327 [ ] Other (Specify) BLANK(S) TO WHICH PROPOSAL APPLIES[ X ] ANNUAL STATEMENT [ ] QUARTERLY STATEMENT [ X ] INSTRUCTIONS [ ] CROSSCHECKS [ X ] BLANK[ X ] Life and Accident & Health [ X ] Property/Casualty [ X ] Health [ ] Separate Accounts [ X ] Fraternal [ X ] Title [ ] Other Specify Anticipated Effective Date: Annual 2012 IDENTIFICATION OF ITEM(S) TO CHANGEAdd an additional line to the Five Year Historical Data page(s) to require companies to specifically identify which amounts of investments reported in the current Investments in Parent, Subsidiary, and Affiliates section are in an immediate or indirect parent.REASON, JUSTIFICATION FOR AND/OR BENEFIT OF CHANGE**Change is requested to correlate information currently being reported in the Quarterly General Interrogatory questions 14.21- 14.28 with information in the Annual statements. Identification of investment in parent on the Annual statement is not currently captured or required to be reported anywhere other than the Notes section. Adding this solitary line to the Five Year Historical Data will allow regulators to monitor these investments and identify changes in these investments more clearly and quickly.NAIC STAFF COMMENTSComment on Effective Reporting Date: Annual 2012 should not be a problem Other Comments:______** This section must be completed on all forms. Revised 6/13/2009© 2012 National Association of Insurance Commissioners 155 ANNUAL STATEMENT BLANK – HEALTHFIVE–YEAR HISTORICAL DATA1 2 3 4 5 2012 2011 2010 2009 2008 Balance Sheet (Pages 2 and 3) 1. Total admitted assets (Page 2, Line 28)...... 2. Total liabilities (Page 3, Line 24)...... 3. Statutory surplus...... 4. Total capital and surplus (Page 3, Line 33)...... Income Statement (Page 4) 5. Total revenues (Line 8)...... 6. Total medical and hospital expenses (Line 18)...... 7. Claims adjustment expenses (Line 20)...... 8. Total administrative expenses (Line 21)...... 9. Net underwriting gain (loss) (Line 24)...... 10. Net investment gain (loss) (Line 27)...... 11. Total other income (Lines 28 plus 29)...... 12. Net income or (loss) (Line 32)...... Cash Flow (Page 6) 13. Net cash from operations (Line 11)...... Risk-Based Capital Analysis 14. Total adjusted capital...... 15. Authorized control level risk-based capital...... Enrollment (Exhibit 1) 16. Total members at end of period (Column 5, Line 7)...... 17. Total members months (Column 6, Line 7)...... Operating Percentage (Page 4) (Item divided by Page 4, sum of Lines 2, 3, and 5) x 100.0 18. Premiums earned plus risk revenue (Line 2 plus Lines 3 and 5) 100.0 100.0 100.0 100.0 100.0 19. Total hospital and medical plus other non-health (Lines 18 plus ...... Line 19)...... 20. Cost containment expenses...... 21. Other claims adjustment expenses...... 22. Total underwriting deductions (Line 23)...... 23. Total underwriting gain (loss) (Line 24)...... Unpaid Claims Analysis (U&I Exhibit, Part 2B) 24. Total claims incurred for prior years (Line 13, Col. 5)...... 25. Estimated liability of unpaid claims-[prior year (Line 13, Col. 6)] ...... Investments In Parent, Subsidiaries and Affiliates 26. Affiliated bonds (Sch. D Summary, Line 12, Col. 1)...... 27. Affiliated preferred stocks (Sch. D Summary, Line 18, Col. 1)...... 28. Affiliated common stocks (Sch. D Summary, Line 24, Col. 1)...... 29. Affiliated short-term investments (subtotal included in Sch. DA Verification, Col. 5, Line 10)...... 30. Affiliated mortgage loans on real estate...... 31. All other affiliated...... 32. Total of above Lines 26 to 31 ...... 33 Total Investment in Parent included in Lines 26 to 31 above. . .NOTE: If a party to a merger, have the two most recent years of this exhibit been restated due to a merger in compliance with the disclosure requirements of SSAP No. 3, Accounting Changes and Correction of Errors? Yes [ ] No [ ] If no, please explain ...... © 2012 National Association of Insurance Commissioners 156 ANNUAL STATEMENT BLANK – LIFEFIVE – YEAR HISTORICAL DATA (Continued)1 2 3 4 5 2012 2011 2010 2009 2008 Investments in Parent, Subsidiaries and Affiliates 44. Affiliated bonds (Sch. D Summary, Line 12, Col. 1)...... 45. Affiliated preferred stocks (Sch. D Summary, Line 18, Col. 1)...... 46. Affiliated common stocks (Sch. D Summary, Line 24, Col. 1)...... 47. Affiliated short-term investments (subtotal included in Schedule DA Verification, Col. 5, Line 10)...... 48. Affiliated mortgage loans on real estate...... 49. All other affiliated...... 50. Total of above Lines 44 to 49...... 51. Total Investment in Parent included in Lines 44 to 49 above ...... Total Nonadmitted and Admitted Assets 5152. Total nonadmitted assets (Page 2, Line 28, Col. 2)...... 5253. Total admitted assets (Page 2, Line 28, Col. 3)...... Investment Data 5354. Net investment income (Exhibit of Net Investment Income)...... 5455. Realized capital gains (losses) (Page 4, Line 34, Column 1)...... 5556. Unrealized capital gains (losses) (Page 4, Line 38, Column 1)...... 5657. Total of above Lines 5354, 54 55 and 5556...... Benefits and Reserve Increase (Page 6) 5758. Total contract benefits-life (Lines 10, 11, 12, 13, 14 and 15, Col.1 minus Lines 10, 11, 12, 13, 14 and 15, Cols. 9, 10 and 11)...... 5859. Total contract benefits-A & H (Lines 13 & 14, Cols. 9, 10 & 11)...... 5960. Increase in life reserves-other than group and annuities (Line 19, Cols. 2 & 3)...... 6061. Increase in A & H reserves (Line 19, Cols. 9, 10 & 11)...... 6162. Dividends to policyholders (Line 30, Col. 1)...... Operating Percentages 6263. Insurance expense percent (Page 6, Col. 1, Lines 21, 22 & 23 less Line 6)/(Page 6 Col. 1, Line 1 plus Exhibit 7, Col. 2, Line 2) x 100.00...... 6364. Lapse percent (ordinary only) [Exhibit of Life Insurance, Column 4, Lines 14 & 15) / ½ (Exhibit of Life Insurance, Column 4, Lines 1 & 21)] x 100.00...... 6465. A & H loss percent (Schedule H, Part 1, Lines 5 & 6, Col. 2)...... 6566. A & H cost containment percent (Schedule H, Part 1, Line 4, Col. 2)...... 6667. A & H expense percent excluding cost containment expenses (Schedule H, Part 1, Line 10, Col. 2)...... A & H Claim Reserve Adequacy 6768. Incurred losses on prior years' claims-group health (Sch. H, Part 3, Line 3.1, Col. 2)...... 6869. Prior years' claim liability and reserve-group health (Sch. H, Part 3, Line 3.2, Col. 2) ...... 6970. Incurred losses on prior years' claims-health other than group (Sch. H, Part 3, Line 3.1, Col. 1 less Col. 2)...... 7071. Prior years' claim liability and reserve-health other than group (Sch. H, Part 3, Line 3.2, Col. 1 less Col. 2)...... Net Gains From Operations After Federal Income Taxes by Lines of Business (Page 6, Line 33) 7172. Industrial life (Col. 2)...... 7273. Ordinary-life (Col. 3)...... 7374. Ordinary-individual annuities (Col. 4)...... 7475. Ordinary-supplementary contracts (Col. 5)...... 7576. Credit life (Col. 6)...... 7677. Group life (Col. 7)...... 7778. Group annuities (Col. 8)...... 7879. A & H-group (Col. 9)...... 7980. A & H-credit (Col. 10)...... 8081. A & H-other (Col. 11)...... 8182. Aggregate of all other lines of business (Col. 12)...... 8283. Total (Col. 1)NOTE: If a party to a merger, have the two most recent years of this exhibit been restated due to a merger in compliance with the disclosure requirements of SSAP No. 3, Accounting Changes and Correction of Errors? Yes [ ] No [ ] If no, please explain ...... © 2012 National Association of Insurance Commissioners 157 ANNUAL STATEMENT BLANK – PROPERTYFIVE–YEAR HISTORICAL DATA Show amounts in whole dollars only, no cents; show percentages to one decimal place, i.e., 17.6. 1 2 3 4 5 2012 2011 2010 2009 2008 Gross Premiums Written (Page 8, Part 1B, Cols. 1, 2 & 3) 1. Liability lines (Lines 11.1, 11.2, 16, 17.1, 17.2, 17.3, 18.1, 18.2, 19.1, 19.2 & 19.3, 19.4) ...... 2. Property lines (Lines 1, 2, 9, 12, 21 & 26)...... 3. Property and liability combined lines (Lines 3, 4, 5, 8, 22 & 27)...... 4. All other lines (Lines 6, 10, 13, 14, 15, 23, 24, 28, 29, 30 & 34)...... 5. Nonproportional reinsurance lines (Lines 31, 32 & 33)...... 6. Total (Line 35)...... Net Premiums Written (Page 8, Part 1B, Col. 6) 7. Liability lines (Lines 11.1, 11.2, 16, 17.1, 17.2, 17.3, 18.1, 18.2, 19.1, 19.2 & 19.3,19.4)...... 8. Property lines (Lines 1, 2, 9, 12, 21 & 26)...... 9. Property and liability combined lines (Lines 3, 4, 5, 8, 22 & 27)...... 10. All other lines (Lines 6, 10, 13, 14, 15, 23, 24, 28, 29, 30 & 34)...... 11. Nonproportional reinsurance lines (Lines 31, 32 & 33)...... 12. Total (Line 35)...... Statement of Income (Page 4) 13. Net underwriting gain (loss) (Line 8)...... 14. Net investment gain (loss) (Line 11)...... 15. Total other income (Line 15)...... 16. Dividends to policyholders (Line 17)...... 17. Federal and foreign income taxes incurred (Line 19)...... 18. Net income (Line 20)...... Balance Sheet Lines (Pages 2 and 3) 19. Total admitted assets excluding protected cell business (Page 2, Line 26, Col. 3) ...... 20. Premiums and considerations (Page 2, Col. 3)...... 20.1 In course of collection (Line 15.1)...... 20.2 Deferred and not yet due (Line 15.2)...... 20.3 Accrued retrospective premiums (Line 15.3)...... 21. Total liabilities excluding protected cell business (Page 3, Line 26)...... 22. Losses (Page 3, Line 1)...... 23. Loss adjustment expenses (Page 3, Line 3)...... 24. Unearned premiums (Page 3, Line 9)...... 25. Capital paid up (Page 3, Lines 30 & 31)...... 26. Surplus as regards policyholders (Page 3, Line 37)...... Cash Flow (Page 5) 27. Net cash from operations (Line 11) ...... Risk-Based Capital Analysis...... 28. Total adjusted capital...... 29. Authorized control level risk-based capital...... Percentage Distribution of Cash, Cash Equivalents and Invested Assets ...... (Page 2, Col. 3) (Item divided by Page 2, Line 12, Col. 3) x 100.0 30. Bonds (Line 1)...... 31. Stocks (Lines 2.1 & 2.2)...... 32. Mortgage loans on real estate (Lines 3.1 and 3.2)...... 33. Real estate (Lines 4.1, 4.2 & 4.3)...... 34. Cash, cash equivalents and short-term investments (Line 5)...... 35. Contract loans (Line 6)...... 36. Derivatives (Line 7) ...... XXX XXX 37. Other invested assets (Line 8)...... 38. Receivables for securities (Line 9)...... 39. Securities lending reinvested collateral assets (Line 10)...... XXX XXX 40. Aggregate write-ins for invested assets (Line 11)...... 41. Cash, cash equivalents and invested assets (Line 12)...... 100.0 100.0 100.0 100.0 100.0 Investments in Parent, Subsidiaries and Affiliates 42. Affiliated bonds, (Sch. D, Summary, Line 12, Col. 1)...... 43. Affiliated preferred stocks (Sch. D, Summary, Line 18, Col. 1)...... 44. Affiliated common stocks (Sch. D, Summary, Line 24, Col. 1)...... 45. Affiliated short-term investments (subtotals included in Schedule DA Verification, Col. 5, Line 10)...... 46. Affiliated mortgage loans on real estate...... 47. All other affiliated...... 48. Total of above Lines 42 to 47...... 49. Total Investment in Parent included in Lines 42 to 47 above ...... 4950. Percentage of investments in parent, subsidiaries and affiliates to surplus as regards policyholders (Line 48 above divided by Page 3, Col. 1, Line 37 x 100.0)© 2012 National Association of Insurance Commissioners 158 FIVE – YEAR HISTORICAL DATA (Continued) 1 2 3 4 5 2012 2011 2010 2009 2008 Capital and Surplus Accounts (Page 4)5051. Net unrealized capital gains (losses) (Line 24)...... 5152. Dividends to stockholders (Line 35)...... 5253. Change in surplus as regards policyholders for the year (Line 38)...... Gross Losses Paid (Page 9, Part 2, Cols. 1 & 2)5354. Liability lines (Lines 11.1, 11.2, 16, 17.1, 17.2, 17.3, 18.1, 18.2, 19.1, 19.2 & 19.3 19.4)...... 5455. Property lines (Lines 1, 2, 9, 12, 21 & 26)...... 5556. Property and liability combined lines (Lines 3, 4, 5, 8, 22 & 27)...... 5657. All other lines (Lines 6, 10, 13, 14, 15, 23, 24, 28, 29, 30 & 34)...... 5758. Nonproportional reinsurance lines (Lines 31, 32 & 33)...... 5859. Total (Line 35)...... Net Losses Paid (Page 9, Part 2, Col. 4)5960. Liability lines (Lines 11.1, 11.2, 16, 17.1, 17.2, 17.3, 18.1, 18.2, 19.1, 19.2 & 19.3, 19.4)...... 6061. Property lines (Lines 1, 2, 9, 12, 21 & 26)...... 6162. Property and liability combined lines (Lines 3, 4, 5, 8, 22 & 27)...... 6263. All other lines (Lines 6, 10, 13, 14, 15, 23, 24, 28, 29, 30 & 34)...... 6364. Nonproportional reinsurance lines (Lines 31, 32 & 33)...... 6465. Total (Line 35)...... Operating Percentages (Page 4) (Item divided by Page 4, Line 1) x 100.06566. Premiums earned (Line 1)...... 100.0 100.0 100.0 100.0 100.0 6667. Losses incurred (Line 2)...... 6768. Loss expenses incurred (Line 3)...... 6869. Other underwriting expenses incurred (Line 4)...... 6910. Net underwriting gain (loss) (Line 8)...... Other Percentages7071. Other underwriting expenses to net premiums written (Page 4, Lines 4+5-15 divided by Page 8, Part 1B, Col. 6, Line 35 x 100.0)...... 7172. Losses and loss expenses incurred to premiums earned (Page 4, Lines 2+3 divided by Page 4, Line 1 x 100.0)...... 7273. Net premiums written to policyholders' surplus (Page 8, Part 1B, Col. 6, Line 35 divided by Page 3, Line 37, Col. 1 x 100.0)...... One Year Loss Development (000 omitted)7374. Development in estimated losses and loss expenses incurred prior to current year (Schedule P, Part 2-Summary, Line 12, Col. 11)...... 7475. Percent of development of losses and loss expenses incurred to policyholders' surplus of prior year end (Line 73 74 above divided by Page 4, Line 21, Col. 1 x 100.0)...... Two Year Loss Development (000 omitted)7576....Development in estimated losses and loss expenses incurred 2 years before the current year and prior year (Schedule P, Part 2-Summary, Line 12, Col. 12)...... 7677...... Percent of development of losses and loss expenses incurred to reported policyholders' surplus of second prior year end (Line 75 76 above divided by Page 4, Line 21, Col. 2 x 100.0)NOTE: If a party to a merger, have the two most recent years of this exhibit been restated due to a merger in compliance with the disclosure requirements of SSAP No. 3, Accounting Changes and Correction of Errors? Yes [ ] No [ ] If no, please explain ...... © 2012 National Association of Insurance Commissioners 159 ANNUAL STATEMENT BLANK – FRATERNALFIVE–YEAR HISTORICAL DATA Show amounts in whole dollars only, no cents; show percentages to one decimal place, i.e. 17.6. Amounts of life insurance in this exhibit should be shown in thousands (OMIT 000). 1 2 3 4 5 2012 2011 2010 2009 2008 Life Insurance in Force (Exhibit of Life Insurance)1. Total (Line 21, Column 2)...... New Business Issued (Exhibit of Life Insurance)2. Total (Line 2, Column 2)...... Premium Income (Exhibit 1, Part 1)3. Life insurance—first year (Line 9.4, Column 2)...... 4. Life insurance—single and renewal (Lines 10.4 and 19.4, Column 2)...... 5. Annuity (Line 20.4, Column 3)...... 6. Accident and health (Line 20.4, Column 4)...... 7. Aggregate of all other lines of business (Line 20.4, Column 5)...... 8. Total (Line 20.4, Column 1)...... Balance Sheet (Pages 2 and 3)9. Total admitted assets excluding Separate Accounts business (Page 2, Line 26, Col. 3)...... 10. Total Liabilities excluding Separate Accounts business (Page 3, Line 23)...... 11. Aggregate reserve for life certificates and contracts (Page 3, Line 1)...... 12. Aggregate reserve for accident and health certificates (Page 3, Line 2)...... 13. Deposit-type contract funds (Page 3, Line 3)...... 14. Asset Valuation Reserve (Page 3, Line 21.1)...... 15. Surplus (Page 3, Line 30)...... Cash Flow (Page 5) 16. Net cash from operations (Line 11) ...... Risk-Based Capital Analysis17. Total adjusted capital...... 18. 50% of the calculated RBC amount...... Percentage Distribution of Cash, Cash Equivalents and Invested Assets (Page 2, Col. 3) (Item No. ÷ Page 2, Line 12, Col. 3) x 100.019. Bonds (Line 1)...... 20. Stocks (Lines 2.1 and 2.2)...... 21. Mortgage loans on real estate (Lines 3.1 and 3.2)...... 22. Real estate (Lines 4.1, 4.2 and 4.3)...... 23. Cash, cash equivalents and short-term investments (Line 5)...... 24. Contract loans (Line 6)...... 25. Derivatives (Line 7) ...... XXX XXX 26. Other invested assets (Line 8)...... 27. Receivables for securities (Line 9)...... 28. Securities lending reinvested collateral assets (Line 10)...... XXX XXX 29. Aggregate write-ins for invested assets (Line 11)...... 30. Cash, cash equivalents and invested assets (Line 12)...... 100.0 100.0 100.0 100.0 100.0 Investments in Subsidiaries and Affiliates31. Affiliated bonds (Schedule D Summary, Line 12, Col. 1)...... 32. Affiliated preferred stock (Schedule D Summary, Line 18, Col. 1)...... 33. Affiliated common stock (Schedule D Summary, Line 24, Col. 1)...... 34. Affiliated short-term investments (subtotals included in ...... Schedule DA Verification, Col. 5, Line 10)...... 35. Affiliated mortgage loans on real estate...... 36. All other affiliated...... 37. Total of above Lines 31 to 36...... 38. Total Investment in Parent included in Lines 31 to 36 above ...... Total Nonadmitted Assets and Admitted Assets3839. Total nonadmitted assets (Page 2, Line 28, Col. 2)...... 3940. Total admitted assets (Page 2, Line 28, Col. 3)...... Investment Data 4041. Net investment income (Exhibit of Net Investment Income, Line 17)...... 4142. Realized capital gains (losses) (Page 4, Line 30, Column 1)...... 4243. Unrealized capital gains (losses) (Page 4, Line 34, Column 1)...... 4344. Total of above Lines 4041, 41 42 and 4243 ...... © 2012 National Association of Insurance Commissioners 160 FIVE – YEAR HISTORICAL DATA (Continued)1 2 3 4 5 2012 2011 2010 2009 2008Benefits and Reserve Increases (Page 6) 4454. Total certificate benefits—life (Lines 10, 11, 12, 13 and 14 Column 7 less Line 13, Column 5)...... 4546. Total certificate benefits—accident and health (Line 13, Column 5)...... ) ...... 4647. Increase in life reserves (Line 17, Column 2)...... 4748. Increase in accident and health reserves (Line 17, Column 5)...... ) ...... 4849. Refunds to members (Line 28, Column 1)...... Operating Percentages ...... 4950. Insurance expense percent (Page 6, Column 1, Lines 19, 20 and 21 less Line 6, Column 1) ÷ (Page 6, Column 1, Line 1) x 100.0...... 5051. Lapse percent [(Exhibit of Life Insurance, Column 2, Lines 14 and 15) / ½ (Exhibit of Life Insurance, Column 2, Lines 1 & 21)] x 100.0...... 5152. Accident and health loss percent (Schedule H, Part 1, Lines 5 and 6, Column 2)...... 5253. A&H cost containment percent (Schedule H, Part 1, Line 4, Column 2)...... 5354. Accident and health expense percent excluding cost containment expenses (Schedule H, Part 1, Line 10, Column 2) ...... Column 1, % Shown) ...... Accident and Health Reserve Adequacy5455. Incurred losses on prior years' claims (Schedule H, Part 3, Line 3.1, ...... Column 1)...... 5556. Prior years' liability and reserve (Schedule H, Part 3, Line 3.2, Column 1)...... Net Gains from Operations After Refunds to Members ...... by Lines of Business (Page 6, Line 29) ...... 5657. Life insurance (Column 2)...... 5758. Annuity (Column 3)...... 5859. Supplementary contracts (Column 4)...... 5960. Accident and health (Column 5)...... 6061. Aggregate of all other lines of business (Column 6)...... 6162. Fraternal (Column 8)...... 6263. Expense (Column 9)...... 6364. Total (Column 1)NOTE: If a party to a merger, have the two most recent years of this exhibit been restated due to a merger in compliance with the disclosure requirements of SSAP No. 3, Accounting Changes and Correction of Errors? Yes [ ] No [ ]If no, please explain ...... © 2012 National Association of Insurance Commissioners 161 ANNUAL STATEMENT BLANK – TITLEFIVE – YEAR HISTORICAL DATA Show amounts in whole dollars only, no cents; show percentages to one decimal place, i.e. 17.6. 1 2 3 4 5 2012 2011 2010 2009 2008 Source of Direct Title Premiums Written (Part 1A)1. Direct operations (Part 1A, Line 1, Col. 1)...... 2. Non-affiliated agency operations (Part 1A, Line 1, Col. 2)...... 3. Affiliated agency operations (Part 1A, Line 1, Col. 3)...... 4. Total ...... Operating Income Summary (Page 4 & Part 1)5. Premiums earned (Part 1B, Line 3)...... 6. Escrow and settlement service charges (Part 1A, Line 2)...... 7. Title examinations (Part 1A, Line 3)...... 8. Searches and abstracts (Part 1A, Line 4)...... 9. Surveys (Part 1A, Line 5)...... 10. Aggregate write-ins for service charges (Part 1A, Line 6)...... 11. Aggregate write-ins for other operating income (Page 4, Line 2)...... 12. Total operating income (Page 4, Line 3)...... Statement of Income (Page 4)13. Net operating gain or (loss) (Line 8)...... 14. Net investment gain or (loss) (Line 11)...... 15. Total other income (Line 12)...... 16. Federal and foreign income taxes incurred (Line 14)...... 17. Net income (Line 15)...... Balance Sheet (Pages 2 and 3)18. Title insurance premiums and fees receivable (Page 2, Line 15, Col. 3)...... 19. Total admitted assets excluding segregated accounts (Page 2, Line 26, Col. 3)...... 20. Known claims reserve (Page 3, Line 1)...... 21. Statutory premium reserve (Page 3, Line 2)...... 22. Total liabilities (Page 3, Line 23)...... 23. Capital paid up (Page 3, Lines 25 + 26)...... 24. Surplus as regards policyholders (Page 3, Line 32)...... Cash Flow (Page 5)25. Net cash from operations (Line 11)...... Percentage Distribution of Cash, Cash-Equivalents and Invested Assets (Page 2, Col. 3) (Item divided by Page 2, Line 12, Col. 3) x 100.026. Bonds (Line 1)...... 27. Stocks (Lines 2.1 & 2.2)...... 28. Mortgage loans on real estate (Line 3.1 and 3.2)...... 29. Real estate (Lines 4.1, 4.2 & 4.3)...... 30. Cash, cash equivalents and short-term investments (Line 5)...... 31. Contract loans (Line 6)...... 32. Derivatives (Line 7) ...... XXX XXX 33. Other invested assets (Line 8)...... 34. Receivable for securities (Line 9)...... 35. Securities lending reinvested collateral assets (Line 10)...... XXX XXX 36. Aggregate write-ins for invested assets (Line 11)...... 37. Subtotals cash, cash equivalents and invested assets (Line 12)...... 100.0 100.0 100.0 100.0 100.0Investments in Parent, Subsidiaries and Affiliates38. Affiliated bonds (Sch. D Summary, Line 12, Col. 1)...... 39. Affiliated preferred stocks (Sch. D, Summary, Line 18, Col. 1)...... 40. Affiliated common stocks (Sch. D, Summary, Line 24, Col. 1)...... 41. Affiliated short-term investments (subtotals included in Schedule DA Verification, Col. 5, Line 10)...... 42. Affiliated mortgage loans on real estate...... 43. All other affiliated...... 44. Total of above Lines 38 to 43...... 45. Total Investment in Parent included in Lines 38 to 43 above ...... 4546. Percentage of investments in parent, subsidiaries and affiliates to surplus as regards policyholders (Line 44 above divided by Page 3, Line 32, Col. 1 x 100.0)© 2012 National Association of Insurance Commissioners 162 FIVE – YEAR HISTORICAL DATA (Continued) 1 2 3 4 5 2012 2011 2010 2009 2008 Capital and Surplus Accounts (Page 4)4647. Net unrealized capital gains or (losses) (Line 18)...... 4748. Change in nonadmitted assets (Line 21)...... 4849. Dividends to stockholders (Line 28)...... 4950. Change in surplus as regards policyholders for the year (Line 31)...... Losses Paid and Incurred (Part 2A)5051. Net payments (Line 5, Col. 4)...... 5152. Losses and allocated LAE incurred (Line 8, Col. 4)...... 5253. Unallocated LAE incurred (Line 9, Col. 4)...... 5354. Losses and loss adjustment expenses incurred (Line 10, Col. 4)...... Operating Expenses to Total Operating Income (Part 3)(%) (Line item divided by Page 4, Line 3 x 100.0)5455. Personnel costs (Part 3, Line 1.5, Col. 4)...... 5556. Amounts paid to or retained by title agents (Part 3, Line 2, Col. 4)...... 5657. All other operating expenses (Part 3, Lines 24 minus 1.5 minus 2, Col. 4)...... 5758. Total (Lines 54 55 to 5657)...... Operating Percentages (Page 4) (Line item divided by Page 4, Line 3 x 100.0)5859. Losses and loss adjustment expenses incurred (Line 4)...... 5960. Operating expenses incurred (Line 5)...... 6061. Other operating expenses (Line 6)...... 6162. Total operating deductions (Line 7)...... 6263. Net operating gain or (loss) (Line 8)...... Other Percentages (Line item divided by Part 1B, Line 1.4 x 100.0)6364. Losses and loss expenses incurred to net premiums written (Page 4, Line 4)...... 6465. Operating expenses incurred to net premiums written (Page 4, Line 5)NOTE: If a party to a merger, have the two most recent years of this exhibit been restated due to a merger in compliance with the disclosure requirements of SSAP No. 3, Accounting Changes and Correction of Errors? Yes [ ] No [ ] If no, please explain ...... © 2012 National Association of Insurance Commissioners 163 ANNUAL STATEMENT INSTRUCTIONS – HEALTHFIVE - YEAR HISTORICAL DATADetail Eliminated To Conserve SpaceInvestments in Parent, Subsidiaries and AffiliatesLine 26 – Affiliated Bonds2009 through current year...... Schedule D Summary, Line 12, Column 1 2008 and prior...... Schedule D Summary, Line 25, Column 1Line 27 – Affiliated Preferred Stocks2009 through current year...... Schedule D Summary, Line 18, Column 1 2008 and prior...... Schedule D Summary, Line 39, Column 1Line 28 – Affiliated Common Stocks2009 through current year...... Schedule D Summary, Line 24, Column 1 2008 and prior...... Schedule D Summary, Line 53, Column 1Line 29 – Affiliated Short-term Investment2008 through current year...... Subtotal included in Schedule DA, Verification Between Years, Column 5, Line 10 2007...... Subtotal included in Schedule DA, Part 2, Column 5, Line 7Line 33 – Total Investment in ParentReport the amount of investments reported Lines 26 to 31 above which are in an immediate or indirect parent.© 2012 National Association of Insurance Commissioners 164 ANNUAL STATEMENT INSTRUCTIONS – LIFEFIVE - YEAR HISTORICAL DATADetail Eliminated To Conserve SpaceInvestments in Parent, Subsidiaries and AffiliatesLine 44 – Affiliated Bonds2009 through current year...... Schedule D Summary, Line 12, Column 1 2008 and prior...... Schedule D Summary, Line 25, Column 1Line 45 – Affiliated Preferred Stocks2009 through current year...... Schedule D Summary, Line 18, Column 1 2008 and prior...... Schedule D Summary, Line 39, Column 1Line 46 – Affiliated Common Stocks2009 through current year...... Schedule D Summary, Line 24, Column 1 2008 and prior...... Schedule D Summary, Line 53, Column 1Line 47 – Affiliated Short-term Investments 2008 through current year...... Subtotal included in Schedule DA, Verification Between Years, Column 5, Line 10 2007...... Subtotal included in Schedule DA, Part 2, Column 5, Line 7Line 51 – Total Investment in ParentReport the amount of investments reported Lines 44 to 49 above which are in an immediate or indirect parent.Total Nonadmitted and Admitted AssetsLine 5152 – Total Nonadmitted Assets2010 through current year...... Page 2, Line 28, Column 2 2009 and prior...... Page 2, Line 26, Column 2Line 5253 – Total Admitted Assets2010 through current year...... Page 2, Line 28, Column 3 2009 and prior...... Page 2, Line 26, Column 3Investment DataLine 5354 – Net Investment IncomeAll years...... Exhibit of Net Investment Income, Line 17Line 5455 – Realized Capital Gains (Losses)All years...... Summary of Operations, Line 34, Column 1Line 5556 – Unrealized Capital Gains (Losses)All years...... Summary of Operations, Line 38, Column 1 © 2012 National Association of Insurance Commissioners 165 Benefits and Reserve Increase (Page 6)Line 5758 – Total Contract Benefits- Life All years...... Lines 10, 11, 12, 13, 14 and 15, Column 1 less Lines 10, 11, 12, 13, 14 and 15 Columns 9, 10 and 11Line 5859 – Total Contract Benefits- A & HAll years...... Lines 13 & 14, Column 9, 10 & 11Line 5960 – Increase in Life Reserves – Other than Group and AnnuitiesAll years...... Line 19, Columns 2 & 3Line 6061 – Increases in A & H ReservesAll years...... Line 19, Columns 9, 10 & 11 Line 6162 – Dividends to PolicyholdersAll years...... Line 30, Column 1Operating PercentagesLine 6263 – Insurance Expense PercentAll years...... (Page 6, Column 1, Lines 21, 22 & 23 less Line 6) / (Page 6, Column 1, Line 1 plus Exhibit 7, Column 2, Line 2) x 100.00Line 6354 – Lapse Percent (ordinary only)All years...... (Exhibit of Life Insurance, Column 4, Lines 14 & 15) / ½ (Exhibit of Life Insurance, Column 4, Lines 1 & 21) x 100.00Line 6465 – A & H Loss PercentAll years...... Schedule H, Part 1, Lines 5 & 6, Column 2Line 6566 – A&H Cost ContainmentAll years...... Schedule H, Part 1, Line 4, Column 2Line 6667 – A & H Expense Percent excluding Cost Containment ExpensesAll years...... Schedule H, Part 1, Line 10, Column 2In 2007, this percentage should exclude Cost Containment Expenses.A & H Claim Reserve AdequacyLine 6768 – Incurred Losses on Prior Years’ Claims – Group HealthAll years...... Schedule H, Part 3, Line 3.1, Column 2Line 6869 – Prior Years’ Claim Liability and Reserve – Group HealthAll years...... Schedule H, Part 3, Line 3.2, Column 2© 2012 National Association of Insurance Commissioners 166 Line 6970 – Incurred Losses on Prior Years’ Claims – Health Other than GroupAll years...... Schedule H, Part 3, Line 3.1, Column 1 less Column 2Line 7071 – Prior Years’ Claim Liability and Reserve – Health Other than GroupAll years...... Schedule H, Part 3, Line 3.2, Column 1 less Column 2Net Gains From Operations After Federal Income Taxes by Lines of BusinessAll years...... Page 6, Line 33Line 7172 – Industrial LifeAll years...... Page 6, Line 33, Column 2Line 7273 – Ordinary – LifeAll years...... Page 6, Line 33, Column 3Line 7374 – Ordinary – Individual AnnuitiesAll years...... Page 6, Line 33, Column 4Line 74 75 – Ordinary – Supplementary ContractsAll years...... Page 6, Line 33, Column 5Line 75 76 – Credit LifeAll years...... Page 6, Line 33, Column 6Line 7677 – Group LifeAll years...... Page 6, Line 33, Column 7Line 7778 – Group AnnuitiesAll years...... Page 6, Line 33, Column 8Line 7879 – A & H – GroupAll years...... Page 6, Line 33, Column 9Line 7980 – A & H – CreditAll years...... Page 6, Line 33, Column 10Line 8081 – A & H – OtherAll years...... Page 6, Line 33, Column 11Line 8182 – Aggregate of All Other Lines of BusinessAll years...... Page 6, Line 33, Column 12© 2012 National Association of Insurance Commissioners 167 ANNUAL STATEMENT INSTRUCTIONS – PROPERTYFIVE - YEAR HISTORICAL DATADetail Eliminated To Conserve SpaceInvestments in Parent, Subsidiaries and AffiliatesLine 42 – Affiliated Bonds2009 through current year...... Schedule D Summary, Line 12, Column 1 2008 and prior ...... Schedule D Summary, Line 25, Column 1Line 43 – Affiliated Preferred Stocks2009 through current year...... Schedule D Summary, Line 18, Column 1 2008 and prior ...... Schedule D Summary, Line 39, Column 1Line 44 – Affiliated Common Stock2009 through current year...... Schedule D Summary, Line 24, Column 1 2008 and prior ...... Schedule D Summary, Line 53, Column 1Line 45 – Affiliated Short-term Investments2008 through current year...... Schedule DA Verification Between Years, Column 5, Line 10 2007...... Schedule DA Part 2, Column 5, Line 7Line 49 – Total Investment in ParentReport the amount of investments reported Lines 42 to 47 above which are in an immediate or indirect parent.Line 4950 – Percentage of Investments in Parents, Subsidiaries and Affiliates to Surplus as Regards Policyholders2010 through current year...... Five Year Historical, Line 48 divided by Page 3, Column 1, Line 37 x 100.0 2009 and prior...... Five Year Historical, Line 46 divided by Page 3, Column 1, Line 35 x 100.0Capital and Surplus Accounts (Page 4)Line 5051 – Net Unrealized Capital Gains (Losses)All Years...... Line 24Line 5152 – Dividends to StockholdersAll Years...... Line 35Line 5253 – Change in Surplus as Regards Policyholders for the YearAll Years...... Line 38Gross Losses PaidAll years...... Page 9, Part 2, Columns 1 & 2Line 5354 – Liability Lines2009 through current year...... Lines 11.1, 11.2, 16, 17.1, 17.2, , 17.3, 18.1, 18.2, 19.1, 19.2, 19.3 & 19.4 2008 and prior...... Lines 11.1, 11.2, 16, 17.1, 17.2, 18.1, 18.2, 19.1, 19.2, 19.3 & 19.4© 2012 National Association of Insurance Commissioners 168 Line 5455 – Property LinesAll years...... Lines 1, 2, 9, 12, 21 & 26Line 5556 – Property and Liability Combined LinesAll years...... Lines 3, 4, 5, 8, 22 & 27Line 5657 – All Other Lines2008 through current year...... Lines 6, 10, 13, 14, 15, 23, 24, 28, 29, 30 & 34 2007...... Lines 6, 10, 13, 14, 15, 23, 24, 28, 29 & 33Line 5758 – Nonproportional Reinsurance Lines2008 through current year...... Lines 31, 32 & 33 2007...... Lines 30, 31 & 32Line 5859 – Total2008 through current year...... Line 35 2007...... Line 34Net Losses PaidAll years Page 9, Part 2, Column 4Line 5960 – Liability Lines2009 through current year...... Lines 11.1, 11.2, 16, 17.1, 17.2, , 17.3, 18.1, 18.2, 19.1, 19.2, 19.3 & 19.4 2008 and prior ...... Lines 11.1, 11.2, 16, 17.1, 17.2, 18.1, 18.2, 19.1, 19.2, 19.3 & 19.4Line 6061 – Property Lines All years...... Lines 1, 2, 9, 12, 21 & 26Line 6162 – Property and Liability Combined LinesAll years...... Lines 3, 4, 5, 8, 22 & 27Line 6263 – All Other Lines2008 through current year...... Lines 6, 10, 13, 14, 15, 23, 24, 28, 29, 30 & 34 2007...... Lines 6, 10, 13, 14, 15, 23, 24, 28, 29 & 33Line 6364 – Nonproportional Reinsurance Lines2008 through current year...... Lines 31, 32 & 33 2007...... Lines 30, 31 & 32Line 6465 – Total2008 through current year...... Line 35 2007...... Line 34© 2012 National Association of Insurance Commissioners 169 Operating Percentages All years...... (Page 4) (Item Divided by Page 4, Line 1) x 100.0Line 6566 – Premiums Earned All years...... Line 1Line 6667 – Losses IncurredAll years...... Line 2Line 6768 – Loss Expenses IncurredAll years...... Line 3Line 6869 – Other Underwriting Expenses IncurredAll years...... Line 4Line 6970 – Net Underwriting Gain (Loss)All years...... Line 8Other PercentagesLine 7071 – Other Underwriting Expenses to Net Premiums WrittenAll years...... Page 4, Lines 4 + 5 – 15 divided by Page 8, Part 1B, Column 6, Line 35 x 100.0Line 7172 – Losses and Loss Expenses Incurred to Premiums EarnedAll years...... Page 4, Lines 2 + 3 divided by Page 4, Line 1 x 100.0 Line 7273 – Net Premiums Written to Policyholders’ Surplus2010 through current year...... Page 8, Part 1B, Column 6, Line 35 divided by Page 3, Line 37, Column 1 x 100.0 2009 and prior...... Page 8, Part 1B, Column 6, Line 35 divided by Page 3, Line 35, Column 1 x 100.0One-Year Loss Development (000 omitted)Line 7374 – Development in Estimated Losses and Loss Expenses Incurred Prior to Current YearAll years...... Schedule P, Part 2 Summary, Line 12, Column 11Line 7475 – Percent of Development of Losses and Loss Expenses Incurred to Policyholders’ Surplus of Prior Year End2010 through current year...... Five Year Historical, Line 73 divided by Page 4, Line 21, Column 1 x 100.0 2007 through 2009...... Five Year Historical, Line 71 divided by Page 4, Line 21, Column 1 x 100.0Two-Year Loss Development (000 omitted)Line 7576 – Development in Estimated Losses and Loss Expenses Incurred 2 Years Before the Current Year and Prior Year All years...... Schedule P, Part 2 Summary Line 12, Column 12Line 7677 – Percent of Development of Losses and Loss Expenses Incurred to Reported Policyholders’ Surplus of Second Year Prior Year End2010 through current year...... Five Year Historical, Line 75 divided by Page 4, Line 21, Column 2 x 100.0 2007 through 2009...... Five Year Historical, Line 73 divided by Page 4, Line 21, Column 2 x 100.0© 2012 National Association of Insurance Commissioners 170 ANNUAL STATEMENT INSTRUCTIONS – FRATERNALFIVE - YEAR HISTORICAL DATADetail Eliminated To Conserve SpaceInvestments in Subsidiaries and AffiliatesLine 31 – Affiliated Bonds2009 through current year...... Schedule D Summary, Line 12, Column 1 2008 and prior...... Schedule D Summary, Line 25, Column 1Line 32 – Affiliated Preferred Stock2009 through current year...... Schedule D Summary, Line 18, Column 1 2008 and prior...... Schedule D Summary, Line 39, Column 1Line 33 – Affiliated Common Stock2009 through current year...... Schedule D Summary, Line 24, Column 1 2008 and prior...... Schedule D Summary, Line 53, Column 1Line 34 – Affiliated Short-term Investments2008 through current year...... Subtotal included in Schedule DA, Verification Between Years, Column 5, Line 10 2007...... Subtotals included in Schedule DA, Part 2, Line 7, Column 5Line 38 – Total Investment in ParentReport the amount of investments reported Lines 31 to 36 above which are in an immediate or indirect parent.Total Nonadmitted Assets and Admitted AssetsLine 3839 – Total Nonadmitted Assets2010 through current year...... Page 2, Line 28, Column 2 2009 and prior...... Page 2, Line 26, Column 2Line 3940 – Total Admitted Assets2010 through current year...... Page 2, Line 28, Column 3 2009 and prior...... Page 2, Line 26, Column 3Investment DataLine 4041 – Net Investment IncomeCurrent year and prior...... Exhibit of Net Investment Income, Line 17Line 4142 – Realized Capital Gains (Losses)All years...... Summary of Operations, Line 30, Column 1Line 4243 – Unrealized Capital Gains (Losses)All years...... Summary of Operations, Line 34, Column 1 © 2012 National Association of Insurance Commissioners 171 Benefits and Reserve Increases (Page 6)Line 4454 – Total Certificate Benefits – lifeAll years...... Lines 10, 11, 12, 13 and 14, Column 7 less Line 13, Column 5Line 4546 – Total Certificate Benefits – Accident and HealthAll years...... Line 13, Column 5Line 46 47– Increase in Life ReservesAll years...... Line 17, Column 2Line 4748 – Increase in Accident and Health ReservesAll years...... Line 17, Column 5Line 4849 – Refunds to MembersAll years...... Line 28, Column 1Operating PercentagesLine 4950 – Insurance Expense PercentAll years...... (Page 6, Column 1, Lines 19, 20 and 21 less Line 6, Column 1) divided by (Page 6, Column 1, Line 1) x 100.0Line 5051 – Lapse PercentAll years...... (Exhibit of Life Insurance, Column 2, Lines 14 & 15) divided ½ (Exhibit of Life Insurance, Column 2, Lines 1 & 21) x 100.0Line 5152 – Accident and Health Loss Percent All years...... Schedule H, Part 1, Lines 5 and 6, Column 2Line 5253 – A&H Cost Containment PercentAll years...... Schedule H, Part 1, Line 4, Column 2Line 5354 – Accident and Health Expense Percent excluding Cost Containment ExpensesAll years...... Schedule H, Part 1, Line 10, Column 2Accident and Health Reserve AdequacyLine 5455 – Incurred Losses on Prior Years’ ClaimsAll years...... Schedule H, Part 3, Line 3.1, Column 1Line 5556 – Prior Years’ Liability and ReserveAll years...... Schedule H, Part 3, Line 3.2, Column 1© 2012 National Association of Insurance Commissioners 172 Net Gains from Operations After Refunds to Members by Lines of BusinessAll years...... Page 6, Line 29Line 5657 – Life InsuranceAll years...... Page 6, Line 29, Column 2Line 5758 – AnnuityAll years...... Page 6, Line 29, Column 3Line 5859 – Supplementary ContractsAll years...... Page 6, Line 29, Column 4Line 5960 – Accident and HealthAll years...... Page 6, Line 29, Column 5Line 6061 – Aggregate of All Other Lines of BusinessAll years...... Page 6, Line 29, Column 6Line 6162 – FraternalAll years...... Page 6, Line 29, Column 8Line 6263 – ExpenseAll years...... Page 6, Line 29, Column 9Line 6364 – Total All years...... Page 6, Line 29, Column 1© 2012 National Association of Insurance Commissioners 173 ANNUAL STATEMENT INSTRUCTIONS – TITLEFIVE - YEAR HISTORICAL DATADetail Eliminated To Conserve SpaceInvestment in Parent, Subsidiaries and AffiliatesLine 38 – Affiliated Bonds2009 through current year...... Schedule D Summary, Line 12, Column 1 2008 and prior...... Schedule D, Summary, Line 25, Column 1Line 39 – Affiliated Preferred Stock2009 through current year...... Schedule D Summary, Line 18, Column 1 2008 and prior...... Schedule D, Summary, Line 39, Column 1Line 40 – Affiliated Common Stock2009 through current year...... Schedule D Summary, Line 24, Column 1 2008 and prior...... Schedule D, Summary, Line 53, Column 1Line 41 – Affiliated Short-term Investments2008 through current year...... Subtotal included in Schedule DA, Verification Between Years, Column 5, Line 10 2007...... Subtotals included in Schedule DA, Part 2, Column 5, Line 7Line 45 – Total Investment in ParentReport the amount of investments reported Lines 38 to 43 above which are in an immediate or indirect parent.Line 4546 – Percentage of Investments in Parent, Subsidiaries and Affiliates to Surplus as Regards to Policyholders2010 through current year...... Line 44 divided by Page 3, Line 32, Column 1 x 100.0 2009 and prior...... Line 42 divided by Page 3, Line 30, Column 1 x 100.0Capital and Surplus AccountsLine 4647 – Net Unrealized Capital Gains (Losses)All years...... Page 4, Line 18 Line 4748 – Change in Nonadmitted AssetsAll years...... Page 4, Line 21Line 4849 – Dividends to StockholdersAll years...... Page 4, Line 28Line 4950 – Change in Surplus as Regards PolicyholdersAll years...... Page 4, Line 31© 2012 National Association of Insurance Commissioners 174 Losses Paid and IncurredAll years...... Operations and Investment Exhibit, Part 2ALine 5051 – Net PaymentsAll years...... Part 2A, Line 5, Column 4Line 5152 – Losses and Allocated LAE IncurredAll years...... Part 2A Line 8, Column 4Line 5253 – Unallocated LAE IncurredAll years...... Part 2A, Line 9, Column 4Line 5354 – Losses and Loss Adjustment Expenses IncurredAll years...... Part 2A, Line 10, Column 4Operating Expenses to Total Operating IncomeAll years...... (Operations and Investment Exhibit, Part 3) (%) (Line item divided by Page 4, Line 3 x 100.0)Line 5455 – Personnel CostsAll years...... Part 3, Line 1.5, Column 4Line 5556 – Amounts Paid To Or Retained By Title AgentsAll years...... Part 3, Line 2, Column 4Line 5657 – All Other Operating ExpensesAll years...... Part 3, Lines 24 minus 1.5 minus 2, Column 4Operating PercentagesAll years...... (Line item divided by Page 4, Line 3 x 100.0)Line 5859 – Losses & Loss Adjustment Expenses IncurredAll years...... Page 4, Line 4Line 5960 – Operating Expenses IncurredAll years...... Page 4, Line 5Line 6061 – Other Operating ExpensesAll years...... Page 4, Line 6Line 6162 – Total Operating DeductionsAll years...... Page 4, Line 7Line 6263 – Net Operating Gain or (Loss)All years...... Page 4, Line 8© 2012 National Association of Insurance Commissioners 175 Other PercentagesAll years...... (Line item divided by Part 1B, Line 1.4 x 100.0)Line 6364 – Losses and Loss Expenses Incurred to Net Premiums WrittenAll years...... Page 4, Line 4Line 6465 – Operating Expenses Incurred to Net Premiums Written All years...... Page 4, Line 5D:\Docs\2018-04-19\0a04292b5410859ee18117748e22c93c.doc© 2012 National Association of Insurance Commissioners 176

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