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NAIC BLANKS (E) WORKING GROUP Blanks Agenda Item Submission Form DATE: 02/03/2012 FOR NAIC USE ONLY Agenda Item # 2012-18BWG MOD Year 2012 Changes to Existing Reporting [X ] New Reporting Requirement [ ] CONTACT PERSON: Heather Davis TELEPHONE: 850-413-5070 EMAIL ADDRESS: Heather. [email protected] REVIEWED FOR ACCOUNTING PRACTICES AND PROCEDURES IMPACT ON BEHALF OF: Florida Office of Insurance Regulation NAME: Toma Wilkerson No Impact [ X ] Modifies Required Disclosure [ DISPOSITION TITLE: Director, Life & Health Financial Oversight AFFILIATION: ADDRESS: 200 East Gaines Street Tallahassee, FL 32399-0327 [ ] [ ] [ X ] [ ] [ ] [ ] [ ] ] Rejected For Public Comment Referred To Another NAIC Group Received For Public Comment Adopted Date Rejected Date Deferred Date Other (Specify) BLANK(S) TO WHICH PROPOSAL APPLIES [X ] [X ] ANNUAL STATEMENT INSTRUCTIONS [ [ ] ] [ X ] Life and Accident & Health [ ] Separate Accounts [ ] Other Specify [X ] [X ] QUARTERLY STATEMENT CROSSCHECKS Property/Casualty Fraternal [X ] [X ] [X ] BLANK Health Title Anticipated Effective Date: Annual 2012 IDENTIFICATION OF ITEM(S) TO CHANGE Add 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 14.2114.28 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 COMMENTS Comment 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 – HEALTH FIVE–YEAR HISTORICAL DATA 1 2012 2 2011 3 2010 4 2009 5 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) ................................................................... ............................. ............................ ............................ ............................ 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) .............................................................................. ............................. ............................ ............................ ............................ 14. Total adjusted capital.................................................................................................... ............................. ............................ ............................ ............................ 15. Authorized control level risk-based capital ................................................................... ............................. ............................ ............................ ............................ 16. Total members at end of period (Column 5, Line 7) ..................................................... ............................. ............................ ............................ ............................ 17. Total members months (Column 6, Line 7) .................................................................. ............................. ............................ ............................ ............................ Income Statement (Page 4) Risk-Based Capital Analysis Enrollment (Exhibit 1) 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 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) ................................................. ............................. ............................ ............................ ............................ ............................. ............................. ............................ ............................ 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 ....................................................................................... ............................. ............................ ............................ ............................ 25. Estimated liability of unpaid claims-[prior year (Line 13, Col. 6)] Investments In Parent, Subsidiaries and Affiliates 100.0 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? If no, please explain ................................................................................................................................................................................... ................................................................................................................................................................................................................... ............................................................................................................................................................................................................ © 2012 National Association of Insurance Commissioners 156 Yes [ ] No [ ] ANNUAL STATEMENT BLANK – LIFE FIVE – YEAR HISTORICAL DATA (Continued) 1 2012 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 52. Total nonadmitted assets (Page 2, Line 28, Col. 2) ............................................................. ..................... 53. Total admitted assets (Page 2, Line 28, Col. 3) .................................................................. ..................... Investment Data 54. Net investment income (Exhibit of Net Investment Income) .............................................. ..................... 55. Realized capital gains (losses) (Page 4, Line 34, Column 1) .............................................. ..................... 56. Unrealized capital gains (losses) (Page 4, Line 38, Column 1) ........................................... 57. Total of above Lines 54, 55 and 56 .................................................................................... ..................... Benefits and Reserve Increase (Page 6) 58. 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) .......................................................................... ..................... 59. Total contract benefits-A & H (Lines 13 & 14, Cols. 9, 10 & 11) ...................................... ..................... 60. Increase in life reserves-other than group and annuities (Line 19, Cols. 2 & 3) ........................................................................................................ ..................... 61. Increase in A & H reserves (Line 19, Cols. 9, 10 & 11) ..................................................... ..................... 62. Dividends to policyholders (Line 30, Col. 1)...................................................................... ..................... Operating Percentages 63. 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 ....................................................... ..................... 64. 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 ................................... ..................... 65. A & H loss percent (Schedule H, Part 1, Lines 5 & 6, Col. 2) ............................................ ..................... 66. A & H cost containment percent (Schedule H, Part 1, Line 4, Col. 2) ................................ ..................... 67. A & H expense percent excluding cost containment expenses (Schedule H, Part 1, Line 10, Col. 2) .................................................................................................................. ..................... A & H Claim Reserve Adequacy 68. Incurred losses on prior years' claims-group health (Sch. H, Part 3, Line 3.1, Col. 2) ........ ..................... 69. Prior years' claim liability and reserve-group health (Sch. H, Part 3, Line 3.2, Col. 2) ........ ..................... 70. Incurred losses on prior years' claims-health other than group (Sch. H, Part 3, Line 3.1, Col. 1 less Col. 2) ........................................................................................................ ..................... 71. 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) 72. Industrial life (Col. 2) ......................................................................................................... ..................... 73. Ordinary-life (Col. 3) ......................................................................................................... ..................... 74. Ordinary-individual annuities (Col. 4)................................................................................ ..................... 75. Ordinary-supplementary contracts (Col. 5) ........................................................................ ..................... 76. Credit life (Col. 6) .............................................................................................................. ..................... 77. Group life (Col. 7) .............................................................................................................. ..................... 78. Group annuities (Col. 8) ..................................................................................................... ..................... 79. A & H-group (Col. 9) ......................................................................................................... ..................... 80. A & H-credit (Col. 10) ....................................................................................................... ..................... 81. A & H-other (Col. 11) ........................................................................................................ ..................... 82. Aggregate of all other lines of business (Col. 12) ............................................................... 83. Total (Col. 1) 2 2011 3 2010 4 2009 ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... .................... .................... .................... ....................... ....................... ....................... ....................... ....................... ....................... .................... .................... ....................... ..................... ....................... ..................... ....................... ..................... .................... ..................... ....................... ....................... ....................... ....................... ....................... ....................... .................... .................... ....................... ....................... ....................... ....................... ....................... ....................... .................... .................... ....................... ....................... ....................... .................... ....................... ....................... ....................... ....................... ....................... ....................... .................... .................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... .................... .................... .................... ....................... ....................... ....................... .................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... .................... .................... .................... ....................... ....................... ....................... .................... ....................... ....................... ....................... ....................... ....................... ....................... .................... .................... ....................... ....................... ....................... .................... ....................... ....................... ....................... .................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... 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? If no, please explain ................................................................................................................................................................................................ ................................................................................................................................................................................................................................. © 2012 National Association of Insurance Commissioners 157 5 2008 Yes [ ] No [ ] ANNUAL STATEMENT BLANK – PROPERTY FIVE–YEAR HISTORICAL DATA Show amounts in whole dollars only, no cents; show percentages to one decimal place, i.e., 17.6. 1 2012 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. Gross Premiums Written (Page 8, Part 1B, Cols. 1, 2 & 3) 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) ....................... Property lines (Lines 1, 2, 9, 12, 21 & 26) ....................................................................... ....................... Property and liability combined lines (Lines 3, 4, 5, 8, 22 & 27) ..................................... ....................... All other lines (Lines 6, 10, 13, 14, 15, 23, 24, 28, 29, 30 & 34) ...................................... ....................... Nonproportional reinsurance lines (Lines 31, 32 & 33) .................................................... Total (Line 35) ................................................................................................................. ....................... Net Premiums Written (Page 8, Part 1B, Col. 6) 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) ......................................................................................................................... ....................... Property lines (Lines 1, 2, 9, 12, 21 & 26) ....................................................................... ....................... Property and liability combined lines (Lines 3, 4, 5, 8, 22 & 27) ..................................... ....................... All other lines (Lines 6, 10, 13, 14, 15, 23, 24, 28, 29, 30 & 34) ...................................... ....................... Nonproportional reinsurance lines (Lines 31, 32 & 33) .................................................... Total (Line 35) ................................................................................................................. ....................... Statement of Income (Page 4) Net underwriting gain (loss) (Line 8) ............................................................................... ....................... Net investment gain (loss) (Line 11) ................................................................................ ....................... Total other income (Line 15) ........................................................................................... ....................... Dividends to policyholders (Line 17) ............................................................................... ....................... Federal and foreign income taxes incurred (Line 19) ....................................................... Net income (Line 20) ....................................................................................................... ....................... Balance Sheet Lines (Pages 2 and 3) Total admitted assets excluding protected cell business (Page 2, Line 26, Col. 3) ............ ....................... 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) ......................................................... ....................... Total liabilities excluding protected cell business (Page 3, Line 26) ................................ ....................... Losses (Page 3, Line 1) .................................................................................................... ....................... Loss adjustment expenses (Page 3, Line 3) ...................................................................... ....................... Unearned premiums (Page 3, Line 9) ............................................................................... ....................... Capital paid up (Page 3, Lines 30 & 31) .......................................................................... ....................... Surplus as regards policyholders (Page 3, Line 37) .......................................................... ....................... Cash Flow (Page 5) Net cash from operations (Line 11) ....................................................................... ....................... ....................... Risk-Based Capital Analysis ......................................................................................... Total adjusted capital ....................................................................................................... ....................... 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 Bonds (Line 1) ................................................................................................................. ....................... Stocks (Lines 2.1 & 2.2) .................................................................................................. ....................... Mortgage loans on real estate (Lines 3.1 and 3.2) ............................................................ ....................... Real estate (Lines 4.1, 4.2 & 4.3) ..................................................................................... ....................... Cash, cash equivalents and short-term investments (Line 5) ............................................ ....................... Contract loans (Line 6) .................................................................................................... ....................... Derivatives (Line 7) ........................................................................................................ ....................... Other invested assets (Line 8) .......................................................................................... ....................... Receivables for securities (Line 9) ................................................................................... ....................... Securities lending reinvested collateral assets (Line 10) ................................................... ....................... Aggregate write-ins for invested assets (Line 11)............................................................. Cash, cash equivalents and invested assets (Line 12) ....................................................... 100.0 Investments in Parent, Subsidiaries and Affiliates Affiliated bonds, (Sch. D, Summary, Line 12, Col. 1)...................................................... ....................... Affiliated preferred stocks (Sch. D, Summary, Line 18, Col. 1) ....................................... ....................... Affiliated common stocks (Sch. D, Summary, Line 24, Col. 1)........................................ ....................... Affiliated short-term investments (subtotals included in Schedule DA Verification, Col. 5, Line 10) ........................................................................................... ....................... Affiliated mortgage loans on real estate ........................................................................... ....................... All other affiliated ............................................................................................................ Total of above Lines 42 to 47........................................................................................... ....................... Total Investment in Parent included in Lines 42 to 47 above ........................................... ....................... 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 2 2011 3 2010 4 2009 ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... XXX ....................... ....................... XXX ....................... ....................... ....................... ....................... ....................... ....................... XXX ....................... ....................... XXX 100.0 100.0 ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ....................... ........................ ........................ ........................ ....................... ....................... ....................... ....................... ....................... ....................... ........................ ........................ ....................... ....................... ....................... ....................... ....................... ....................... ........................ ....................... 100.0 5 2008 100.0 FIVE – YEAR HISTORICAL DATA (Continued) 1 2012 2 2011 3 2010 4 2009 5 2008 ................. ................. ................. ................ ................ ................ ............... ............... ............... ................ ................ ................ ............... ............... ............... ................. ................. ................. ................ ................ ................ ............... ............... ............... ................ ................ ................ ............... ............... ............... ................. ................ ............... ................ ............... ................. ................ ............... ................ ............... ................. ................. ................. ................. ................ ................ ................ ................ ............... ............... ............... ............... ................ ................ ................ ................ ............... ............... ............... ............... ................. ................ ............... ................ ............... 100.0 ................. ................. ................. ................. 100.0 ................ ................ ................ ................ 100.0 ............... ............... ............... ............... 100.0 ................ ................ ................ ................ 100.0 ............... ............... ............... ............... ................. ................ ............... ................ ............... ................. ................ ............... ................ ............... ................. ................ ............... ................ ............... ................. ................ ............... ................ ............... ................. ................ ............... ................ ............... ................. ................ ............... ................ ............... Capital and Surplus Accounts (Page 4) 51. 52. 53. Net unrealized capital gains (losses) (Line 24) ........................................................................... Dividends to stockholders (Line 35) .......................................................................................... Change in surplus as regards policyholders for the year (Line 38) ............................................. Gross Losses Paid (Page 9, Part 2, Cols. 1 & 2) 54. 55. 56. 57. 58. 59. 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) ........ Property lines (Lines 1, 2, 9, 12, 21 & 26) ................................................................................. Property and liability combined lines (Lines 3, 4, 5, 8, 22 & 27) ............................................... All other lines (Lines 6, 10, 13, 14, 15, 23, 24, 28, 29, 30 & 34) ...................................................................... Nonproportional reinsurance lines (Lines 31, 32 & 33) ............................................................. Total (Line 35) ........................................................................................................................... Net Losses Paid (Page 9, Part 2, Col. 4) 60. 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) ........ 61. Property lines (Lines 1, 2, 9, 12, 21 & 26) ................................................................................. 62. Property and liability combined lines (Lines 3, 4, 5, 8, 22 & 27) ................................................ 63. All other lines (Lines 6, 10, 13, 14, 15, 23, 24, 28, 29, 30 & 34) ................................................ 64. Nonproportional reinsurance lines (Lines 31, 32 & 33) .............................................................. 65. Total (Line 35) ........................................................................................................................... Operating Percentages (Page 4) (Item divided by Page 4, Line 1) x 100.0 66. 67. 68. 69. 10. Premiums earned (Line 1) .......................................................................................................... Losses incurred (Line 2) ............................................................................................................ Loss expenses incurred (Line 3) ................................................................................................. Other underwriting expenses incurred (Line 4) ......................................................................... Net underwriting gain (loss) (Line 8) ......................................................................................... Other Percentages 71. 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) .............................................................................. 72. Losses and loss expenses incurred to premiums earned (Page 4, Lines 2+3 divided by Page 4, Line 1 x 100.0) ......................................................................................................... 73. 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) 74. 75. Development in estimated losses and loss expenses incurred prior to current year (Schedule P, Part 2-Summary, Line 12, Col. 11) ............................................................................................ Percent of development of losses and loss expenses incurred to policyholders' surplus of prior year end (Line 74 above divided by Page 4, Line 21, Col. 1 x 100.0)................ Two Year Loss Development (000 omitted) 76. 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) ................................................. 77. Percent of development of losses and loss expenses incurred to reported policyholders' surplus of second prior year end (Line 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? If no, please explain ............................................................................................................................................................. .............................................................................................................................................................................................. © 2012 National Association of Insurance Commissioners 159 Yes [ ] No [ ] ANNUAL STATEMENT BLANK – FRATERNAL FIVE–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 2012 2 2011 3 2010 4 2009 5 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. 4. 5. 6. 7. 8. Life insurance—first year (Line 9.4, Column 2) ........................................................................ ......................... Life insurance—single and renewal (Lines 10.4 and 19.4, Column 2) ....................................... ......................... Annuity (Line 20.4, Column 3) .................................................................................................. ......................... Accident and health (Line 20.4, Column 4) ............................................................................... ......................... Aggregate of all other lines of business (Line 20.4, Column 5) .................................................. ......................... Total (Line 20.4, Column 1) ...................................................................................................... ......................... 9. 10. 11. 12. 13. 14. 15. Total admitted assets excluding Separate Accounts business (Page 2, Line 26, Col. 3) ........................................................................................................................................ ......................... Total Liabilities excluding Separate Accounts business (Page 3, Line 23) ................................. ......................... Aggregate reserve for life certificates and contracts (Page 3, Line 1) ......................................... ......................... Aggregate reserve for accident and health certificates (Page 3, Line 2) ...................................... ......................... Deposit-type contract funds (Page 3, Line 3) ............................................................................. ......................... Asset Valuation Reserve (Page 3, Line 21.1) ............................................................................. ......................... Surplus (Page 3, Line 30) .......................................................................................................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... 16. Cash Flow (Page 5) Net cash from operations (Line 11) .......................................................................................... ......................... ......................... ......................... ......................... .......................... ......................... ......................... ......................... ......................... ......................... ......................... .......................... .......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... 100.0 ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... 100.0 ......................... ......................... ......................... ......................... ......................... ......................... XXX ......................... ......................... XXX ......................... 100.0 .......................... .......................... .......................... .......................... .......................... .......................... XXX .......................... .......................... XXX .......................... 100.0 ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... .......................... .......................... .......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... .......................... .......................... .......................... .......................... .......................... ......................... ......................... ......................... ......................... ......................... ......................... .......................... .......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... .......................... .......................... .......................... Balance Sheet (Pages 2 and 3) Risk-Based Capital Analysis 17. 18. Total adjusted capital ................................................................................................................. ......................... 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 100.0 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. Bonds (Line 1) ........................................................................................................................... ......................... Stocks (Lines 2.1 and 2.2) ......................................................................................................... ......................... Mortgage loans on real estate (Lines 3.1 and 3.2) ...................................................................... ......................... Real estate (Lines 4.1, 4.2 and 4.3) ............................................................................................ ......................... Cash, cash equivalents and short-term investments (Line 5) ...................................................... ......................... Contract loans (Line 6) .............................................................................................................. ......................... Derivatives (Line 7) .................................................................................................................. ......................... Other invested assets (Line 8) .................................................................................................... ......................... Receivables for securities (Line 9) ............................................................................................. ......................... Securities lending reinvested collateral assets (Line 10) ............................................................. ......................... Aggregate write-ins for invested assets (Line 11) ...................................................................... ......................... Cash, cash equivalents and invested assets (Line 12) ................................................................. 100.0 Investments in Subsidiaries and Affiliates 31. 32. 33. 34. 35. 36. 37. 38. Affiliated bonds (Schedule D Summary, Line 12, Col. 1) ........................................................... ......................... Affiliated preferred stock (Schedule D Summary, Line 18, Col. 1) ............................................ ......................... Affiliated common stock (Schedule D Summary, Line 24, Col. 1)............................................. ......................... Affiliated short-term investments (subtotals included in Schedule DA Verification, Col. 5, Line 10) ............................................................................... ......................... Affiliated mortgage loans on real estate ..................................................................................... ......................... All other affiliated ..................................................................................................................... ......................... Total of above Lines 31 to 36 .................................................................................................... ......................... Total Investment in Parent included in Lines 31 to 36 above ..................................................... ......................... Total Nonadmitted Assets and Admitted Assets 39. 40. Total nonadmitted assets (Page 2, Line 28, Col. 2) .................................................................... ......................... Total admitted assets (Page 2, Line 28, Col. 3) .......................................................................... ......................... Investment Data 41. 42. 43. 44. Net investment income (Exhibit of Net Investment Income, Line 17) ........................................ ......................... Realized capital gains (losses) (Page 4, Line 30, Column 1) ...................................................... ......................... Unrealized capital gains (losses) (Page 4, Line 34, Column 1) ................................................... ......................... Total of above Lines 41, 42 and 43 © 2012 National Association of Insurance Commissioners 160 FIVE – YEAR HISTORICAL DATA (Continued) 1 2012 2 2011 3 2010 4 2009 5 2008 Total certificate benefits—life (Lines 10, 11, 12, 13 and 14 Column 7 less Line 13, Column 5) ................................................................................ ........................ ....................... ....................... ........................ ....................... 46. Total certificate benefits—accident and health (Line 13, Column 5) ............................. ........................ ) ....................... ....................... ........................ ....................... 47. Increase in life reserves (Line 17, Column 2) ................................................................ ........................ ....................... ....................... ........................ ....................... 48. Increase in accident and health reserves (Line 17, Column 5) ....................................... ........................ ) ....................... ....................... ........................ ....................... 49. Refunds to members (Line 28, Column 1) ..................................................................... ........................ ....................... ....................... ........................ ....................... 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 .......................................................... ........................ ....................... ....................... ........................ ....................... 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 ...................................... ........................ ....................... ....................... ........................ ....................... 52. Accident and health loss percent (Schedule H, Part 1, Lines 5 and 6, Column 2) .......... ........................ ....................... ....................... ........................ ....................... 53. A&H cost containment percent (Schedule H, Part 1, Line 4, Column 2) ....................... ........................ ....................... ....................... ........................ ....................... 54. Accident and health expense percent excluding cost containment expenses (Schedule H, Part 1, Line 10, Column 2) ...................................................................... ........................ Column ....................... 1, % Shown) ....................... ........................ ....................... Benefits and Reserve Increases (Page 6) 54. Operating Percentages 50. 51. Accident and Health Reserve Adequacy 55. 56. Incurred losses on prior years' claims (Schedule H, Part 3, Line 3.1, Column 1) ..................................................................................................................... ........................ ....................... ....................... ........................ ....................... 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) 57. Life insurance (Column 2) ............................................................................................ ........................ ....................... ....................... ........................ ....................... 58. Annuity (Column 3) ...................................................................................................... ........................ ....................... ....................... ........................ ....................... 59. Supplementary contracts (Column 4) ............................................................................ ........................ ....................... ....................... ........................ ....................... 60. Accident and health (Column 5) .................................................................................... ........................ ....................... ....................... ........................ ....................... 61. Aggregate of all other lines of business (Column 6) ...................................................... ........................ ....................... ....................... ........................ ....................... 62. Fraternal (Column 8) ..................................................................................................... ........................ ....................... ....................... ........................ ....................... 63. Expense (Column 9)...................................................................................................... ........................ ....................... ....................... ........................ ....................... 64. 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? If no, please explain ................................................................................................................................................................................ ................................................................................................................................................................................................................. © 2012 National Association of Insurance Commissioners 161 Yes [ ] No [ ] ANNUAL STATEMENT BLANK – TITLE FIVE – YEAR HISTORICAL DATA Show amounts in whole dollars only, no cents; show percentages to one decimal place, i.e. 17.6. 1 2012 2 2011 3 2010 4 2009 5 2008 Source of Direct Title Premiums Written (Part 1A) 1. 2. 3. 4. Direct operations (Part 1A, Line 1, Col. 1) ....................................................................................... Non-affiliated agency operations (Part 1A, Line 1, Col. 2)............................................................... Affiliated agency operations (Part 1A, Line 1, Col. 3) ................................................ Total ................................................................................................................................................ ..................... ..................... ..................... ..................... ..................... ..................... ...................... ...................... ..................... ..................... ..................... ...................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ...................... ...................... ...................... ..................... ..................... ..................... ...................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ..................... ..................... ..................... ...................... ..................... ..................... ..................... ..................... ..................... ..................... XXX ..................... ..................... ..................... ..................... ..................... XXX ...................... ...................... ...................... ...................... ...................... ...................... XXX ...................... Operating Income Summary (Page 4 & Part 1) 5. 6. 7. 8. 9. 10. 11. 12. Premiums earned (Part 1B, Line 3) .................................................................................................. Escrow and settlement service charges (Part 1A, Line 2) ................................................................. Title examinations (Part 1A, Line 3) ................................................................................................ Searches and abstracts (Part 1A, Line 4) .......................................................................................... Surveys (Part 1A, Line 5) ................................................................................................................. Aggregate write-ins for service charges (Part 1A, Line 6) ................................................................ Aggregate write-ins for other operating income (Page 4, Line 2) ..................................................... Total operating income (Page 4, Line 3) .......................................................................................... Statement of Income (Page 4) 13. 14. 15. 16. 17. Net operating gain or (loss) (Line 8) ................................................................................................ Net investment gain or (loss) (Line 11) ............................................................................................ Total other income (Line 12) ............................................................................................................ Federal and foreign income taxes incurred (Line 14) .................................................. Net income (Line 15) ....................................................................................................................... Balance Sheet (Pages 2 and 3) 18. 19. 20. 21. 22. 23. 24. Title insurance premiums and fees receivable (Page 2, Line 15, Col. 3) ........................................... Total admitted assets excluding segregated accounts (Page 2, Line 26, Col. 3) .......................................... Known claims reserve (Page 3, Line 1) ............................................................................................ Statutory premium reserve (Page 3, Line 2) ..................................................................................... Total liabilities (Page 3, Line 23) ..................................................................................................... Capital paid up (Page 3, Lines 25 + 26) ........................................................................................... 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 100.0 26. 27. 28. 29. 30. 31. 32. 33. Bonds (Line 1) ................................................................................................................................. Stocks (Lines 2.1 & 2.2) .................................................................................................................. Mortgage loans on real estate (Line 3.1 and 3.2) .............................................................................. Real estate (Lines 4.1, 4.2 & 4.3) ..................................................................................................... Cash, cash equivalents and short-term investments (Line 5)............................................................. Contract loans (Line 6)..................................................................................................................... Derivatives (Line 7) ........................................................................................................................ Other invested assets (Line 8) .......................................................................................................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ...................... ..................... 34. Receivable for securities (Line 9) ..................................................................................................... ..................... ..................... 35. 36. 37. Securities lending reinvested collateral assets (Line 10) ................................................................... Aggregate write-ins for invested assets (Line 11) ........................................................ Subtotals cash, cash equivalents and invested assets (Line 12) .................................... 100.0 ..................... ...................... 100.0 100.0 100.0 ...................... XXX 100.0 Investments in Parent, Subsidiaries and Affiliates 38. 39. 40. 41. 42. 43. 44. 45. 46. Affiliated bonds (Sch. D Summary, Line 12, Col. 1) ........................................................................ Affiliated preferred stocks (Sch. D, Summary, Line 18, Col. 1)........................................................ Affiliated common stocks (Sch. D, Summary, Line 24, Col. 1) ........................................................ Affiliated short-term investments (subtotals included in Schedule DA Verification, Col. 5, Line 10) ........................................................................................................... Affiliated mortgage loans on real estate ........................................................................................... All other affiliated ....................................................................................................... Total of above Lines 38 to 43 ........................................................................................................... Total Investment in Parent included in Lines 38 to 43 above ........................................................... 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 2012 2 2011 3 2010 4 2009 5 2008 ........................ ........................ ........................ ........................ ....................... ....................... ....................... ....................... ........................ ........................ ........................ ........................ ....................... ....................... ....................... ....................... ........................ ........................ ....................... ....................... ........................ ........................ ....................... ....................... Capital and Surplus Accounts (Page 4) 47. 48. 49. 50. Net unrealized capital gains or (losses) (Line 18) ...................................................................... Change in nonadmitted assets (Line 21) .................................................................................... Dividends to stockholders (Line 28) .......................................................................................... Change in surplus as regards policyholders for the year (Line 31) ............................................. Losses Paid and Incurred (Part 2A) 51. 52. Net payments (Line 5, Col. 4) .................................................................................................... Losses and allocated LAE incurred (Line 8, Col. 4) .................................................................. ........................ ........................ 53. 54. Unallocated LAE incurred (Line 9, Col. 4) ................................................................................ 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) 55. 56. 57. 58. Personnel costs (Part 3, Line 1.5, Col. 4) ................................................................................... Amounts paid to or retained by title agents (Part 3, Line 2, Col. 4) ............................................ All other operating expenses (Part 3, Lines 24 minus 1.5 minus 2, Col. 4)................... Total (Lines 55 to 57) ................................................................................................................ Operating Percentages (Page 4) (Line item divided by Page 4, Line 3 x 100.0) 59. 60. Losses and loss adjustment expenses incurred (Line 4) ............................................................. Operating expenses incurred (Line 5) ........................................................................................ ........................ ........................ 61. 62. 63. Other operating expenses (Line 6) ............................................................................................. Total operating deductions (Line 7) .................................................................... Net operating gain or (loss) (Line 8) .......................................................................................... ........................ ....................... ....................... ....................... ....................... ........................ ....................... ........................ ....................... ........................ ....................... ........................ ....................... Other Percentages (Line item divided by Part 1B, Line 1.4 x 100.0) 64. Losses and loss expenses incurred to net premiums written (Page 4, Line 4) ...... 65. 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? If no, please explain ............................................................................................................................................................................ ............................................................................................................................................................................................................. © 2012 National Association of Insurance Commissioners 163 Yes [ ] No [ ] ANNUAL STATEMENT INSTRUCTIONS – HEALTH FIVE-YEAR HISTORICAL DATA Detail Eliminated To Conserve Space Investments in Parent, Subsidiaries and Affiliates Line 26 – Affiliated Bonds 2009 through current year ....... Schedule D Summary, Line 12, Column 1 2008 and prior ......................... Schedule D Summary, Line 25, Column 1 Line 27 – Affiliated Preferred Stocks 2009 through current year ....... Schedule D Summary, Line 18, Column 1 2008 and prior ......................... Schedule D Summary, Line 39, Column 1 Line 28 – Affiliated Common Stocks 2009 through current year ....... Schedule D Summary, Line 24, Column 1 2008 and prior ......................... Schedule D Summary, Line 53, Column 1 Line 29 – Affiliated Short-term Investment 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 7 Line 33 – Total Investment in Parent Report the amount of investments reported in Lines 26 to 31 above which are in an immediate or indirect parent. © 2012 National Association of Insurance Commissioners 164 ANNUAL STATEMENT INSTRUCTIONS – LIFE FIVE-YEAR HISTORICAL DATA Detail Eliminated To Conserve Space Investments in Parent, Subsidiaries and Affiliates Line 44 – Affiliated Bonds 2009 through current year ....... Schedule D Summary, Line 12, Column 1 2008 and prior ......................... Schedule D Summary, Line 25, Column 1 Line 45 – Affiliated Preferred Stocks 2009 through current year ....... Schedule D Summary, Line 18, Column 1 2008 and prior ......................... Schedule D Summary, Line 39, Column 1 Line 46 – Affiliated Common Stocks 2009 through current year ....... Schedule D Summary, Line 24, Column 1 2008 and prior ......................... Schedule D Summary, Line 53, Column 1 Line 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 7 Line 51 – Total Investment in Parent Report the amount of investments reported in Lines 44 to 49 above which are in an immediate or indirect parent. Total Nonadmitted and Admitted Assets Line 52 – Total Nonadmitted Assets 2010 through current year ....... Page 2, Line 28, Column 2 2009 and prior ......................... Page 2, Line 26, Column 2 Line 53 – Total Admitted Assets 2010 through current year ....... Page 2, Line 28, Column 3 2009 and prior ......................... Page 2, Line 26, Column 3 Investment Data Line 54 – Net Investment Income All years .................................. Exhibit of Net Investment Income, Line 17 Line 55 – Realized Capital Gains (Losses) All years .................................. Summary of Operations, Line 34, Column 1 Line 56 – 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 58 – 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 11 Line 59 – Total Contract Benefits- A & H All years .................................. Lines 13 & 14, Column 9, 10 & 11 Line 60 – Increase in Life Reserves – Other than Group and Annuities All years .................................. Line 19, Columns 2 & 3 Line 61 – Increases in A & H Reserves All years .................................. Line 19, Columns 9, 10 & 11 Line 62 – Dividends to Policyholders All years .................................. Line 30, Column 1 Operating Percentages Line 63 – Insurance Expense Percent All 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 100.00 Line 54 – 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 100.00 Line 65 – A & H Loss Percent All years .................................. Schedule H, Part 1, Lines 5 & 6, Column 2 Line 66 – A&H Cost Containment All years .................................. Schedule H, Part 1, Line 4, Column 2 Line 67 – A & H Expense Percent excluding Cost Containment Expenses All years .................................. Schedule H, Part 1, Line 10, Column 2 In 2007, this percentage should exclude Cost Containment Expenses. A & H Claim Reserve Adequacy Line 68 – Incurred Losses on Prior Years’ Claims – Group Health All years .................................. Schedule H, Part 3, Line 3.1, Column 2 Line 69 – Prior Years’ Claim Liability and Reserve – Group Health All years .................................. Schedule H, Part 3, Line 3.2, Column 2 © 2012 National Association of Insurance Commissioners 166 Line 70 – Incurred Losses on Prior Years’ Claims – Health Other than Group All years .................................. Schedule H, Part 3, Line 3.1, Column 1 less Column 2 Line 71 – Prior Years’ Claim Liability and Reserve – Health Other than Group All years .................................. Schedule H, Part 3, Line 3.2, Column 1 less Column 2 Net Gains From Operations After Federal Income Taxes by Lines of Business All years .................................. Page 6, Line 33 Line 72 – Industrial Life All years .................................. Page 6, Line 33, Column 2 Line 73 – Ordinary – Life All years .................................. Page 6, Line 33, Column 3 Line 74 – Ordinary – Individual Annuities All years .................................. Page 6, Line 33, Column 4 Line 75 – Ordinary – Supplementary Contracts All years .................................. Page 6, Line 33, Column 5 Line 76 – Credit Life All years .................................. Page 6, Line 33, Column 6 Line 77 – Group Life All years .................................. Page 6, Line 33, Column 7 Line 78 – Group Annuities All years .................................. Page 6, Line 33, Column 8 Line 79 – A & H – Group All years .................................. Page 6, Line 33, Column 9 Line 80 – A & H – Credit All years .................................. Page 6, Line 33, Column 10 Line 81 – A & H – Other All years .................................. Page 6, Line 33, Column 11 Line 82 – Aggregate of All Other Lines of Business All years .................................. Page 6, Line 33, Column 12 © 2012 National Association of Insurance Commissioners 167 ANNUAL STATEMENT INSTRUCTIONS – PROPERTY FIVE-YEAR HISTORICAL DATA Detail Eliminated To Conserve Space Investments in Parent, Subsidiaries and Affiliates Line 42 – Affiliated Bonds 2009 through current year ....... Schedule D Summary, Line 12, Column 1 2008 and prior ........................ Schedule D Summary, Line 25, Column 1 Line 43 – Affiliated Preferred Stocks 2009 through current year ....... Schedule D Summary, Line 18, Column 1 2008 and prior ........................ Schedule D Summary, Line 39, Column 1 Line 44 – Affiliated Common Stock 2009 through current year ....... Schedule D Summary, Line 24, Column 1 2008 and prior ........................ Schedule D Summary, Line 53, Column 1 Line 45 – Affiliated Short-term Investments 2008 through current year ....... Schedule DA Verification Between Years, Column 5, Line 10 2007 ......................................... Schedule DA Part 2, Column 5, Line 7 Line 49 – Total Investment in Parent Report the amount of investments reported in Lines 42 to 47 above which are in an immediate or indirect parent. Line 50 – Percentage of Investments in Parents, Subsidiaries and Affiliates to Surplus as Regards Policyholders 2010 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 100.0 Capital and Surplus Accounts (Page 4) Line 51 – Net Unrealized Capital Gains (Losses) All Years ................................. Line 24 Line 52 – Dividends to Stockholders All Years ................................. Line 35 Line 53 – Change in Surplus as Regards Policyholders for the Year All Years ................................. Line 38 Gross Losses Paid All years .................................. Page 9, Part 2, Columns 1 & 2 Line 54 – Liability Lines 2009 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 55 – Property Lines All years .................................. Lines 1, 2, 9, 12, 21 & 26 Line 56 – Property and Liability Combined Lines All years .................................. Lines 3, 4, 5, 8, 22 & 27 Line 57 – All Other Lines 2008 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 & 33 Line 58 – Nonproportional Reinsurance Lines 2008 through current year ....... Lines 31, 32 & 33 2007 ......................................... Lines 30, 31 & 32 Line 59 – Total 2008 through current year ....... Line 35 2007 ......................................... Line 34 Net Losses Paid All years Page 9, Part 2, Column 4 Line 60 – Liability Lines 2009 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 Line 61 – Property Lines All years .................................. Lines 1, 2, 9, 12, 21 & 26 Line 62 – Property and Liability Combined Lines All years .................................. Lines 3, 4, 5, 8, 22 & 27 Line 63 – All Other Lines 2008 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 & 33 Line 64 – Nonproportional Reinsurance Lines 2008 through current year ....... Lines 31, 32 & 33 2007 ......................................... Lines 30, 31 & 32 Line 65 – Total 2008 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 100.0 Line 66 – Premiums Earned All years .................................. Line 1 Line 67 – Losses Incurred All years .................................. Line 2 Line 68 – Loss Expenses Incurred All years .................................. Line 3 Line 69 – Other Underwriting Expenses Incurred All years .................................. Line 4 Line 70 – Net Underwriting Gain (Loss) All years .................................. Line 8 Other Percentages Line 71 – Other Underwriting Expenses to Net Premiums Written All years .................................. Page 4, Lines 4 + 5 – 15 divided by Page 8, Part 1B, Column 6, Line 35 x 100.0 Line 72 – Losses and Loss Expenses Incurred to Premiums Earned All years .................................. Page 4, Lines 2 + 3 divided by Page 4, Line 1 x 100.0 Line 73 – Net Premiums Written to Policyholders’ Surplus 2010 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 100.0 One-Year Loss Development (000 omitted) Line 74 – Development in Estimated Losses and Loss Expenses Incurred Prior to Current Year All years .................................. Schedule P, Part 2 Summary, Line 12, Column 11 Line 75 – Percent of Development of Losses and Loss Expenses Incurred to Policyholders’ Surplus of Prior Year End 2010 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 100.0 Two-Year Loss Development (000 omitted) Line 76 – 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 12 Line 77 – Percent of Development of Losses and Loss Expenses Incurred to Reported Policyholders’ Surplus of Second Year Prior Year End 2010 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 – FRATERNAL FIVE-YEAR HISTORICAL DATA Detail Eliminated To Conserve Space Investments in Subsidiaries and Affiliates Line 31 – Affiliated Bonds 2009 through current year ....... Schedule D Summary, Line 12, Column 1 2008 and prior ......................... Schedule D Summary, Line 25, Column 1 Line 32 – Affiliated Preferred Stock 2009 through current year ....... Schedule D Summary, Line 18, Column 1 2008 and prior ......................... Schedule D Summary, Line 39, Column 1 Line 33 – Affiliated Common Stock 2009 through current year ....... Schedule D Summary, Line 24, Column 1 2008 and prior ......................... Schedule D Summary, Line 53, Column 1 Line 34 – Affiliated Short-term Investments 2008 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 5 Line 38 – Total Investment in Parent Report the amount of investments reported in Lines 31 to 36 above which are in an immediate or indirect parent. Total Nonadmitted Assets and Admitted Assets Line 39 – Total Nonadmitted Assets 2010 through current year ....... Page 2, Line 28, Column 2 2009 and prior ......................... Page 2, Line 26, Column 2 Line 40 – Total Admitted Assets 2010 through current year ....... Page 2, Line 28, Column 3 2009 and prior ......................... Page 2, Line 26, Column 3 Investment Data Line 41 – Net Investment Income Current year and prior ............. Exhibit of Net Investment Income, Line 17 Line 42 – Realized Capital Gains (Losses) All years .................................. Summary of Operations, Line 30, Column 1 Line 43 – 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 54 – Total Certificate Benefits – life All years .................................. Lines 10, 11, 12, 13 and 14, Column 7 less Line 13, Column 5 Line 46 – Total Certificate Benefits – Accident and Health All years .................................. Line 13, Column 5 Line 4647– Increase in Life Reserves All years .................................. Line 17, Column 2 Line 48 – Increase in Accident and Health Reserves All years .................................. Line 17, Column 5 Line 49 – Refunds to Members All years .................................. Line 28, Column 1 Operating Percentages Line 50 – Insurance Expense Percent All years .................................. (Page 6, Column 1, Lines 19, 20 and 21 less Line 6, Column 1) divided by (Page 6, Column 1, Line 1) x 100.0 Line 51 – Lapse Percent All years .................................. (Exhibit of Life Insurance, Column 2, Lines 14 & 15) divided ½ (Exhibit of Life Insurance, Column 2, Lines 1 & 21) x 100.0 Line 52 – Accident and Health Loss Percent All years .................................. Schedule H, Part 1, Lines 5 and 6, Column 2 Line 53 – A&H Cost Containment Percent All years .................................. Schedule H, Part 1, Line 4, Column 2 Line 54 – Accident and Health Expense Percent excluding Cost Containment Expenses All years .................................. Schedule H, Part 1, Line 10, Column 2 Accident and Health Reserve Adequacy Line 55 – Incurred Losses on Prior Years’ Claims All years .................................. Schedule H, Part 3, Line 3.1, Column 1 Line 56 – Prior Years’ Liability and Reserve All 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 Business All years .................................. Page 6, Line 29 Line 57 – Life Insurance All years .................................. Page 6, Line 29, Column 2 Line 58 – Annuity All years .................................. Page 6, Line 29, Column 3 Line 59 – Supplementary Contracts All years .................................. Page 6, Line 29, Column 4 Line 60 – Accident and Health All years .................................. Page 6, Line 29, Column 5 Line 61 – Aggregate of All Other Lines of Business All years .................................. Page 6, Line 29, Column 6 Line 62 – Fraternal All years .................................. Page 6, Line 29, Column 8 Line 63 – Expense All years .................................. Page 6, Line 29, Column 9 Line 64 – Total All years .................................. Page 6, Line 29, Column 1 © 2012 National Association of Insurance Commissioners 173 ANNUAL STATEMENT INSTRUCTIONS – TITLE FIVE-YEAR HISTORICAL DATA Detail Eliminated To Conserve Space Investment in Parent, Subsidiaries and Affiliates Line 38 – Affiliated Bonds 2009 through current year ....... Schedule D Summary, Line 12, Column 1 2008 and prior ......................... Schedule D, Summary, Line 25, Column 1 Line 39 – Affiliated Preferred Stock 2009 through current year ....... Schedule D Summary, Line 18, Column 1 2008 and prior ......................... Schedule D, Summary, Line 39, Column 1 Line 40 – Affiliated Common Stock 2009 through current year ....... Schedule D Summary, Line 24, Column 1 2008 and prior ......................... Schedule D, Summary, Line 53, Column 1 Line 41 – Affiliated Short-term Investments 2008 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 7 Line 45 – Total Investment in Parent Report the amount of investments reported in Lines 38 to 43 above which are in an immediate or indirect parent. Line 46 – Percentage of Investments in Parent, Subsidiaries and Affiliates to Surplus as Regards to Policyholders 2010 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 100.0 Capital and Surplus Accounts Line 47 – Net Unrealized Capital Gains (Losses) All years .................................. Page 4, Line 18 Line 48 – Change in Nonadmitted Assets All years .................................. Page 4, Line 21 Line 49 – Dividends to Stockholders All years .................................. Page 4, Line 28 Line 50 – Change in Surplus as Regards Policyholders All years .................................. Page 4, Line 31 © 2012 National Association of Insurance Commissioners 174 Losses Paid and Incurred All years .................................. Operations and Investment Exhibit, Part 2A Line 51 – Net Payments All years .................................. Part 2A, Line 5, Column 4 Line 52 – Losses and Allocated LAE Incurred All years .................................. Part 2A Line 8, Column 4 Line 53 – Unallocated LAE Incurred All years .................................. Part 2A, Line 9, Column 4 Line 54 – Losses and Loss Adjustment Expenses Incurred All years .................................. Part 2A, Line 10, Column 4 Operating Expenses to Total Operating Income All years .................................. (Operations and Investment Exhibit, Part 3) (%) (Line item divided by Page 4, Line 3 x 100.0) Line 55 – Personnel Costs All years .................................. Part 3, Line 1.5, Column 4 Line 56 – Amounts Paid To Or Retained By Title Agents All years .................................. Part 3, Line 2, Column 4 Line 57 – All Other Operating Expenses All years .................................. Part 3, Lines 24 minus 1.5 minus 2, Column 4 Operating Percentages All years .................................. (Line item divided by Page 4, Line 3 x 100.0) Line 59 – Losses & Loss Adjustment Expenses Incurred All years .................................. Page 4, Line 4 Line 60 – Operating Expenses Incurred All years .................................. Page 4, Line 5 Line 61 – Other Operating Expenses All years .................................. Page 4, Line 6 Line 62 – Total Operating Deductions All years .................................. Page 4, Line 7 Line 63 – Net Operating Gain or (Loss) All years .................................. Page 4, Line 8 © 2012 National Association of Insurance Commissioners 175 Other Percentages All years .................................. (Line item divided by Part 1B, Line 1.4 x 100.0) Line 64 – Losses and Loss Expenses Incurred to Net Premiums Written All years .................................. Page 4, Line 4 Line 65 – Operating Expenses Incurred to Net Premiums Written All years .................................. 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