NAIC BLANKS (E) WORKING GROUP

Blanks Agenda Item Submission Form

DATE: 07/18/2014

CONTACT PERSON:

TELEPHONE:

EMAIL ADDRESS:

ON BEHALF OF:

NAME: Joseph Torti III

TITLE: Co-Chair Principle-based Reserving

Implementation (EX) Task Force

AFFILIATION: RI Division of Insurance and Banking

ADDRESS: 1511 Pontiac Ave, Bldg. 69-2

Cranston, RI 02920-4407

FOR NAIC USE ONLYAgenda Item # 2014-18BWG MOD Year 2014 Changes to Existing Reporting [ ]New Reporting Requirement [ X ]

REVIEWED FOR ACCOUNTING PRACTICES AND PROCEDURES IMPACT

No Impact [ X ]Modifies Required Disclosure [ ]

DISPOSITION

[ ] Rejected For Public Comment[ ] Referred To Another NAIC Group[ ] Received For Public Comment[ X ] Adopted Date 09/19/2014 [ ] Rejected Date [ ] Deferred Date [ ] Other (Specify)

BLANK(S) TO WHICH PROPOSAL APPLIES

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

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

Anticipated Effective Date: Annual 2014

IDENTIFICATION OF ITEM(S) TO CHANGE

Add a new Supplemental XXX/AXXX Reinsurance Exhibit (Parts 1, 2, 3 and 4) to the Life and Fraternal blank.

NOTE: Property, Health and Title are included in this proposal only because the bar code list is uniform for all statement types.

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

The purpose of this proposal is to add the Supplemental XXX/AXXX Reinsurance Exhibit contemplated by the XXX/AXXX Reinsurance Transactions Framework adopted in concept by the Principle-Based Reserving Implementation (EX) Task Force on June 30, 2014.

NAIC STAFF COMMENTS

Comment on Effective Reporting Date:

Other Comments:

_____________________________________________________________________________________________________** This section must be completed on all forms. Revised 6/13/2009

© 2014 National Association of Insurance Commissioners 191

ANNUAL STATEMENT INSTRUCTIONS – LIFE AND FRATERNAL

SUPPLEMENT AL XXX/AXXX REINSURANCE EXHIBIT

PART 1 – ALL XXX AND AXXX CESSIONS

This exhibit is required to be filed no later than April 1.

Part 1 applies to all cessions of those certain life insurance policies required to be valued under the Section 6 of the NAIC Valuation of Life Insurance Policies Model Regulation (#830) (exempting policies under Section 6E, 6F, or 6G), commonly referred to as Regulation XXX, or to ULSG policies required to be valued under Section 7 of Regulation XXX as further clarified by the NAIC Actuarial Guideline XXXVIII – The Application of the Valuation of Life Insurance Policies Model Regulation (A.G. 38), commonly referred to as AXXX by the reporting entity, regardless of the effective date of the cession or the issue date of the policies.

Column 1 – NAIC Company Code

Provide the NAIC code of the assuming insurer.

Column 2 – ID Number

Enter one of the following as appropriate for the assuming insurer reported on the schedule. See the Schedule S General Instructions for more information on these identification numbers.

Federal Employer Identification Number (FEIN)Alien Insurer Identification Number (AIIN)Certified Reinsurer Identification Number (CRIN)

Column 3 – Name of Company

Provide the name of the assuming insurer.

Column 4 – LicensedAuthorized Reinsurer (YES/NO)

Enter “YES”, if the reinsurance was ceded to an assuming insurer that meets licensed to transact insurance or reinsurance in the applicable requirements reporting entity’s state of domicile within the meaning of Section 2.A. of the NAIC Credit for Reinsurance Model Law (Model 785), as adopted in the reporting entity’s state of domicile, and that, in addition, satisfies the criteria for Exemption described in Actuarial Guideline XLVIII Actuarial Opinion and Memorandum Requirements for the Reinsurance of Policies Required to be Valued under Sections 6 and 7 of the NAIC Valuation of Life Insurance Policies Model Regulation (Model 830) (a) as adopted by the NAIC Life Actuarial (A) Task Force (“LATF”) or; (b) if not adopted by LATF prior to January 1, 2015, in the form exposed by LATF on August 14, 2014 (“AG-48”). is described in Section [[insert]] of Actuarial Guideline [[insert no. here]] “Treatment of Reinsurance for Policies required to be Valued under Sections 6 and 7 of the NAIC Valuation of Life Insurance Policies Model Regulation in the Actuarial Opinion.”

Column 5 – Accredited Reinsurer (YES/NO)

Enter “YES”, if the reinsurance was ceded to an assuming insurer that meets is accredited by the applicable requirements commissioner of the reporting entity’s state of domicile within the meaning of Section 2.B. of the NAIC Credit for Reinsurance Model Law (Model 785), as adopted in the reporting entity’s state of domicile and that, in addition satisfies the criteria for Exemption described in AG-48., is described in Section [[insert]] of Actuarial Guideline [[insert no. here]] “Treatment of Reinsurance for Policies required to be Valued under Sections 6 and 7 of the NAIC Valuation of Life Insurance Policies Model Regulation in the Actuarial Opinion.”

© 2014 National Association of Insurance Commissioners 192

Column 6 – Certified Reinsurer (YES/NO)

Enter “YES”, if the reinsurance was ceded to an assuming insurer that meets has been certified by the applicable requirements commissioner as a reinsurer in this state within the meaning of Section 2.E. of the NAIC Credit for Reinsurance Model Law (Model 785), as adopted in the reporting entity’s state of domicile.

Column 7 – Reinsurer Domiciled in Another Jurisdiction State (YES/NO)

Enter “YES”, if the reinsurance was ceded to an assuming insurer that meets is domiciled in another jurisdiction state within the applicable requirements meaning of Section 2.C. of the NAIC Credit for Reinsurance Model Law (Model 785), as adopted in the reporting entity’s state of domicile and that, in addition, satisfies the criteria for Exemption described in AG-48.is described in Section [[insert]] of Actuarial Guideline [[insert no. here]] “Treatment of Reinsurance for Policies required to be Valued under Sections 6 and 7 of the NAIC Valuation of Life Insurance Policies Model Regulation in the Actuarial Opinion.”

Column 8 Reinsurer Maintaining Trust Fund (YES/NO)

Enter “YES”, if the reinsurance was ceded to an assuming insurer that meets maintaining trust funds within the applicable requirements meaning of Section 2.D. of the NAIC Credit for Reinsurance Model Law (Model 785), as adopted in the reporting entity’s state of domicile, and that, in addition, satisfies the criteria for Exemption described in AG-48.

Column 9 Reinsurance Required by Law (YES/NO)

Enter “YES”, if the reinsurance risk is located in jurisdictions where the reinsurance is required by law or regulation within the meaning of Section 2.F. of the NAIC Credit for Reinsurance Model Law (Model 785), as adopted in the reporting entity’s state of domicile.

Column 10 – Affiliate Related Party Captive / SPV (YES/NO)

Enter “YES”, if the assuming insurer identified in Column 3 is an affiliatea related party captive or special purpose vehicle.

Column 11 – Effective Inception Date

Provide the effective inception date of the reinsurance ceding arrangement.

Column 12 – Statutory Reserve Credit Taken

Provide the dollar amount of the full statutory reserve credit taken amount for all XXX and AXXX products included in the ceded reinsurance contract.

Column 12 should equal the sum of Column 13 and Column 14.

Column 13 – XXX Statutory Policy Reserve Credit TakenCeded

Provide the dollar amount of XXX statutory policy reserves credit takenceded. For reserves subject to modified coinsurance, report the modified coinsurance reserve.

Column 14 – AXXX Statutory Policy Reserve Credit TakenCeded

Provide the dollar amount of AXXX statutory policy reserves credit takenceded. For reserves subject to modified coinsurance, report the modified coinsurance reserve.

© 2014 National Association of Insurance Commissioners 193

SUPPLEMENT AL XXX/AXXX REINSURANCE EXHIBIT

PART 2 – TRANSACTIONS SUBJECT TO PART 2 DISCLOSURE

This exhibit is required to be filed no later than April 1.

Part 2 applies to all cessions identified in Part 1 except cessions as to which Column 4, 5, 6, 7, 8, or 9 is reported as “YES”. Defined terms used herein shall have the meaning ascribed to them in AG-48. The terms “Primary Security Level”, “Primary Security” and “Other Security” shall have the meaning given to them in Actuarial Guideline [[insert no. here]] “Treatment of Reinsurance for Policies required to be Valued under Sections 6 and 7 of the NAIC Valuation of Life Insurance Policies Model Regulation in the Actuarial Opinion”

For purposes of Parts 2, the word “collateral” shall mean assets retained by the ceding company through a modified-coinsurance or funds withheld basis and assets held in trust for the benefit of the ceding company, or, if the case of a letter of credit, in the possession of the ceding company or held in trust for the benefit of the ceding company. Collateral also includes parental guarantees made payable to the ceding company.

Except as otherwise provided in Columns 9 and 16, all asset values, For assets that would be admitted under the NAIC Accounting Practices and Procedures Manual if they were held by the reporting entity and without taking into consideration any prescribed or permitted practices, and including for assets held in trust, the values are to be determined according to statutory accounting proceduresin a manner consistent with valuation requirements applicable to reinsurance collateral under the NAIC Accounting Practices and Procedures Manual as if such assets were held in the ceding reporting insurer’s general account. If the ceding company cannot determine the statutory accounting value of certain assets under the NAIC Accounting Practices and Procedures Manual after making a diligent effort to do so, the ceding company can report that asset using the value assigned to the asset for the purpose of determining the amount of reserve credit taken; provided, however, any such assets must be reported on a line separate from those assets valued in accordance with the NAIC Accounting Practices and Procedures Manual and the insurer shall make a note indicating the basis for the valuation used.

For all other assets, the values are to be those that were assigned to the collateral for the purpose of determining the amount of reserve credit taken.

Column 1 – Cession ID

Enter a unique Cession ID for each line (01 – 99).

Column 2 – NAIC Company Code

Provide the NAIC code of the assuming insurer.

Column 3 – ID Number

Enter one of the following as appropriate for the assuming insurer being reported on the schedule. See the Schedule S General Instructions for more information on these identification numbers.

Federal Employer Identification Number (FEIN)Alien Insurer Identification Number (AIIN)Certified Reinsurer Identification Number (CRIN)

Column 4 – Name of Company

Provide the name of the assuming insurer.

Column 5 – EffectiveInception Date or Prior Year Annual Statement Date

Provide the later latter of the effectiveinception date of the cession or the annual statement date immediately preceding the current annual statement date.

© 2014 National Association of Insurance Commissioners 194

As of Effective Inception Date or Prior Year’s Annual Statement

Column 6 – Reserve Credit Taken

State the dollar amount of the reserve credit taken by the reporting entity as of the date reported in Column 5.

Column 7 – Required Level of Primary Security Level

State the Required Level of Primary Security applicable Level applied to the statutory policy reserves as of date reported in Column 5. This Column is not applicable for the period ending December 31, 2014.

Column 8 – Primary Security

State the value as of the date reported in Column 5 of the Primary Security forms received by the reporting entity as collateral.

Column 9 – Primary Security Valuation by Reinsurer

If different than the amount stated in Column 8, state the value, as shown on the books of the assuming insurer, as of the date reported in Column 5 of the Primary Security forms received by the reporting entity as collateral.

Column 109 – Primary Security – Trust

State the value as of the date reported in Column 5 of any part of the collateral reported in Column 8 that is held in trust for the benefit of the reporting entity.

Column 1110 – Primary Security – Funds Withheld or Modified-Coinsurance

State the value as the date reported in Column 5 of any part of the collateral reported in Column 8 that is held by the reporting entity on a funds withheld basis or on a modified coinsurance basis.

Column 1211 – Other Security

State the value as of the date reported in Column 5 of all collateral that is not reported in Column 8.

As of Current Year’s Annual Statement

Column 1312 – Reserve Credit Taken

State the dollar amount of the reserve credit taken by the reporting entity as of the current annual statement date.

Column 1413 – Required Level of Primary Security Level

State the Required Level of Primary Security Level applicable applied to the statutory policy reserves as of the current annual statement date. This Column is not applicable for the period ending December 31, 2014.

Column 1514 – Primary Security

State the value as of the current annual statement date of the Primary Security forms received by the reporting entity as collateral.

© 2014 National Association of Insurance Commissioners 195

Column 16 – Primary Security Valuation by Reinsurer

If different than the amount stated in Column 15, state the value, as shown on the books of the assuming insurer, as of the date reported in Column 15 of the Primary Security forms received by the reporting entity as collateral.

Column 1715 – Primary Security Adjustment

If Column 1413 is greater than Column 1514, state the value as of the current annual statement date of any additional Primary Security received by the reporting entity after the as of date of the current annual statement as collateral to cover the difference. This Column is not applicable for the period ending December 31, 2014.

Column 1816 – Primary Security – Trust

State the value as of the current annual statement date of any part of the collateral reported in Column 1514 orand Column 1615 that is held in trust for the benefit of the reporting entity.

Column 1917 – Primary Security – Funds Withheld or Modified-Coinsurance

State the value as of the current annual statement date of any part of the collateral reported in Column 1514 orand Column 1715 that is held by the reporting entity on a funds withheld basis or on a modified coinsurance basis.

Column 2018 – Other Security

State the value as of the current annual statement date of all collateral with respect to the transaction that is not reported in Columns 1514 orand 1615.

© 2014 National Association of Insurance Commissioners 196

SUPPLEMENT AL XXX/AXXX REINSURANCE EXHIBIT

PART 3 – COLLATERAL FOR ALL XXX/AXXX REINSURANCE TRANSACTIONS REPORTED ON PART 2

This exhibit is required to be filed no later than April 1.

Part 3 applies to all the cessions of identified in Part 2; provided, however, that if the reporting entity has not received any collateral in connection with a cession identified in Part 2, the only information required is the Cession ID number, Name of Company, NAIC Company Code, and ID Number. The reporting entity should prepare a separate page for each Cession ID reported on Part 2. The reporting entity should also provide a Grand Total page.

For each Cession ID, the information regarding the Name of the Company; the NAIC Company Code; the ID Number; and the inception date or prior year annual statement date should match what was reported for those columns on Part 2.

For purposes of Parts 2, the word “collateral” shall mean assets retained by the ceding company through a modified-coinsurance or funds withheld basis and assets held in trust for the benefit of the ceding company, or, if the case of a letter of credit, in the possession of the ceding company or held in trust for the benefit of the ceding company. Collateral also includes parental guarantees made payable to the ceding company.

All asset valuesFor assets that would be admitted under the NAIC Accounting Practices and Procedures Manual if they were held by the reporting entity and without taking into consideration any prescribed or permitted practices, and including assets forheld in trust, the values are to be determined according to statutory accounting procedures in a manner consistent with valuation requirements applicable to reinsurance collateral under the NAIC Accounting Practices and Procedures Manual as if such assets were held in the reporting entity’s ceding insurer’s general account. If the ceding company cannot determine the statutory accounting value of certain assets under the NAIC Accounting Practices and Procedures Manual after making a diligent effort to do so, the ceding company can report that asset using the value assigned to the asset for the purpose of determining the amount of reserve credit taken; provided, however, any such assets must be reported on a line separate from those assets valued in accordance with the NAIC Accounting Practices and Procedures Manual and the insurer shall make a note indicating the basis for the valuation used.

For all other assets, the values are to be those that were assigned to the collateral for the purpose of determining the amount of reserve credit taken.

The reporting entity shall report the amount of assets in which collateral supporting the cession may be held corresponding to the categories shown below:

Group or Category Line Number

Primary Security

Cash .................................................................................................................................................................0199999

NAIC 1 SVO-Listed Securities .......................................................................................................................0299999

NAIC 2 SVO-Listed Securities .......................................................................................................................0399999

NAIC 23 SVO-Listed Securities .....................................................................................................................0499999

NAIC 4 SVO-Listed Securities .......................................................................................................................0599999

NAIC 5 SVO-Listed Securities .......................................................................................................................0699999

NAIC 56 SVO-Listed Securities .....................................................................................................................0799999

Evergreen, Unconditional LOCs .....................................................................................................................0899999

Other Primary Security per AG 48 (if any) .....................................................................................................0999999

Subtotal Primary Security ................................................................................................................................1099999

© 2014 National Association of Insurance Commissioners 197

Other Security

Cash .................................................................................................................................................................0999999

NAIC 1 SVO-Listed Securities .......................................................................................................................1099999

NAIC 2 SVO-Listed Securities .......................................................................................................................1199999

NAIC 3 SVO-Listed Securities .......................................................................................................................1299999

NAIC 4 SVO-Listed Securities .......................................................................................................................1399999

NAIC 5 SVO-Listed Securities .......................................................................................................................1499999

NAIC 6 SVO-Listed Securities .......................................................................................................................1599999

Other Investments Admissible per the NAIC AP&P Manual ....................................................................161199999

Evergreen, Unconditional LOCs .....................................................................................................................1799999

Other LOCs .................................................................................................................................................181299999

All Other Assets ..........................................................................................................................................191399999

Total ...............................................................................................................................................................................9999999

As of Effective Inception Date or Prior Year’s Annual Statement

Column 1 – Assets

State the value as of the latter of the effective inception date of the cession or the annual statement date immediately preceding the current annual statement date for collateral held in each category identified. Report Except for 2014 reporting, report cash, SVO securities, and evergreen, unconditional LOCs held as Primary SecurityAssets separately from cash, SVO securities and evergreen, unconditional LOCs held as Other Security.

For the Grand Total page, the total for Column 3 should equal Part 2, Column 98 plus 1211

Column 2 – Affiliate or Parental Guarantee (YES/NO)

Indicate as to any asset identified in Column 1 as to which an affiliate of the reporting entity has issued a guarantee.

As of Current Year’s Annual Statement

Column 3 – Assets

State the value as of the current annual statement date for collateral held in each category identified. Except for 2014 reporting, report Report cash, SVO securities, and evergreen, unconditional LOCs held as Primary Security separately from cash, SVO securities and evergreen, unconditional LOCs held as Other Security.

For the Grand Total page, the total for Column 3 should equal Part 2, Column 1514 plus 1918

Column 4 – Affiliate or Parental Guarantee (YES/NO)

Enter “YES”, if any asset identified in Column 3 as to which an affiliate of the reporting entity has issued a guarantee.

© 2014 National Association of Insurance Commissioners 198

SUPPLEMENT AL XXX/AXXX REINSURANCE EXHIBIT

PART 4 – NON-COLLATERAL ASSETS SUPPORTING RESERVES FOR ALL AFFILIATE XXX/AXXX REINSURANCE TRANSACTIONS REPORTED ON PART 2

This exhibit is required to be filed no later than April 1.

Part 4 applies to all the cessions identified in Part 2 in which the assuming insurer is an affiliate of the reporting entity. The reporting entity should prepare a separate page for each Cession ID required to be reported on Part 4. The reporting entity should also provide a Grand Total page.

For each Cession ID, the information regarding the Name of the Company; the NAIC Company Code; the ID Number; and the inception date or prior year annual statement date should match what was reported for those columns on Part 2.

For assets that would be admitted under the NAIC Accounting Practices and Procedures Manual if they were held by the reporting entity and without taking into consideration any prescribed or permitted practices, and including assets held in trust, the values are to be determined according to statutory accounting procedures under the NAIC Accounting Practices and Procedures Manual as if such assets were held in the reporting entity’s general account. For all other assets, the values are to be those that were assigned to the assets on the financial statements of the assuming insurer.

The reporting entity shall report the amount of assets corresponding to the categories shown below:

Group or Category Line Number

Cash .................................................................................................................................................................0199999

NAIC 1 SVO-Listed Securities .......................................................................................................................0299999

NAIC 2 SVO-Listed Securities .......................................................................................................................0399999

NAIC 3 SVO-Listed Securities .......................................................................................................................0499999

NAIC 4 SVO-Listed Securities .......................................................................................................................0599999

NAIC 5 SVO-Listed Securities .......................................................................................................................0699999

NAIC 6 SVO-Listed Securities .......................................................................................................................0799999

Other Investments Admissible per the NAIC AP&P Manual ........................................................................0899999

Evergreen, Unconditional LOCs .....................................................................................................................0999999

Other LOCs .....................................................................................................................................................1099999

All Other Assets ..............................................................................................................................................1199999

Total ...............................................................................................................................................................................9999999

As of Effective Date or Prior Year’s Annual Statement

Column 1 – Non-Collateral Assets Supporting Reserves – Affiliate Transactions

In each category identified, state the value, as of the later of the effective date of the cession or the annual statement date immediately preceding the current annual statement date, for all assets held by the assuming insurer in support of the cession and not held as collateral, but not including assets supporting liabilities not covered by the cession. If the assuming insurer holds assets supporting the cession and other liabilities, the assuming insurer, for purposes of this Part 4, should make an allocation of assets by liability and should report here only the assets allocated to the cession. Do not include any asset reported in Part 3.

Column 2 – Affiliate or Parental Guarantee (YES/NO)

Indicate as to any asset identified in Column 1 as to which an affiliate of the reporting entity has issued a guarantee.

© 2014 National Association of Insurance Commissioners 199

As of Current Year’s Annual Statement

Column 3 – Non-Collateral Assets Supporting Reserves – Affiliate Transactions

In each category identified, state the value, as of the current annual statement date, for all assets held by the assuming insurer in support of the cession and not held as collateral, but not including assets supporting liabilities not covered by the cession. If the assuming insurer holds assets supporting the cession and other liabilities, the assuming insurer, for purposes of this Part 4, should make an allocation of assets by liability and should report here only the assets allocated to the cession. Do not include any asset reported in Part 3.

Column 4 – Affiliate or Parental Guarantee (YES/NO)

Enter “YES”, if any asset identified in Column 3 as to which an affiliate of the reporting entity has issued a guarantee.

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

APPENDIX

INSTRUCTIONS FOR USE OF BARCODES

Detail Eliminated To Conserve Space

FORMDOCUMENT IDENTIFIER

Statement (Annual, Quarterly and Combined).........................................................................................................................201Separate Accounts Statement...................................................................................................................................................202Protected Cell Statement...........................................................................................................................................................203

Detail Eliminated To Conserve Space

Long-Term Care Experience Reporting Form 1.......................................................................................................................301Long-Term Care Experience Reporting Form 2.......................................................................................................................302Long-Term Care Experience Reporting Form 3.......................................................................................................................303Long-Term Care Experience Reporting Form 4.......................................................................................................................304Long-Term Care Experience Reporting Form 5.......................................................................................................................305Supplemental Exhibits and Schedules Interrogatories – LTC Forms.......................................................................................306Supplemental XXX/AXXX Reinsurance Exhibit .............................................................................................. .......................345Management’s Discussion and Analysis of Operations............................................................................................................350Medicare Supplement Insurance Experience Exhibit................................................................................................................360

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© 2014 National Association of Insurance Commissioners 200

© 2014 National Association of Insurance Commissioners 201

ANNUAL STATEMENT BLANK – LIFE AND FRATERNAL

SUPPLEMENT FOR THE YEAR OF THE

Affix Bar Code Above

SUPPLEMENTAL XXX/AXXX REINSURANCE EXHIBIT

For the Year Ended December 31, ____(To Be Filed by April 1)

OF THE ______________________________

NAIC Group Code __________ NAIC Company Code __________

PART 1 – ALL XXX AND AXXX CESSIONS

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

NAIC Company

Code ID Number Name of Company

Authorized Licensed Reinsurer (YES/NO)

Accredited Reinsurer (YES/NO)

Certified Reinsurer (YES/NO)

Reinsurer Domiciled in

Another Jurisdiction

State (YES/NO)

Reinsurer Maintaining Trust Fund (YES/NO)

Reinsurance Required by

Law (YES/NO)

Related Party Captive /

SPV Affiliate (YES/NO)

Effective Inception

DateStatutory Reserve

Credit Taken

XXX Statutory Policy Reserve Credit Taken

Ceded

AXXX Statutory Policy Reserve Credit Taken

Ceded

9999999Total

© 2014 National Association of Insurance Commissioners 202

PART 2 – TRANSACTIONS SUBJECT TO PART 2 DISCLOSURE

1 2 3 4 5 As of Effective Inception Date or Prior Year’s Annual Statement As of Current Year’s Annual Statement6 7 8 9 109 1110 1211 1312 1413 1514 16 1715 1816 1917 2018

Cession ID

NAIC Company

CodeID

Number Name of Company

Inception Effective

Date or Prior Year Annual

Statement Date

Reserve Credit Taken

Required Level of Primary

Security LevelPrimary Security

Primary Security

Valuation by Reinsurer

Primary Security –

Trust

Primary Security –

Funds Withheld or Modified-

Coinsurance Other SecurityReserve Credit

Taken

Required Level of Primary

Security LevelPrimary Security

Primary Security

Valuation by Reinsurer

Primary Security

Adjustment

Primary Security –

Trust

Primary Security –

Funds Withheld or Modified-

Coinsurance Other SecurityXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXXXXX XXX XXX

9999999Total XXX XXX XXX

© 2014 National Association of Insurance Commissioners 203

PART 3 – COLLATERAL FOR ALL XXX/AXXX REINSURANCE TRANSACTIONS REPORTED ON PART 2

Part 2 Cession ID __________

Name of Company: ________________________________

NAIC Company Code __________ ID Number __________

Effective Inception Date or Prior Year Annual Statement Date: __________

As of Effective Inception Date or Prior Year’s Annual Statement

As of Current Year’s Annual Statement

1 2 3 4

Security Category Description Assets

Affiliate or Parental

Guarantee (YES/NO) Assets

Affiliate or Parental

Guarantee (YES/NO)

9999999 Total XXX XXX

Note: The description provided for the Security Category Description Column will be the category line number and description found in the instructions.

© 2014 National Association of Insurance Commissioners 204

PART 4 – NON-COLLATERAL ASSETS SUPPORTING RESERVES FOR ALL AFFILIATE XXX/AXXX REINSURANCE TRANSACTIONS REPORTED ON PART 2

Part 2 Cession ID __________

Name of Company: ________________________________

NAIC Company Code __________ ID Number __________

Effective Date or Prior Year Annual Statement Date: __________

Asset Category Description

As of Effective Date or Prior Year’s Annual Statement

As of Current Year’s Annual Statement

1Non-Collateral

Assets Supporting Reserves – Affiliate

Transactions

2Affiliate or

Parental Guarantee (YES/NO)

3Non-Collateral

Assets Supporting Reserves – Affiliate

Transactions

4Affiliate or

Parental Guarantee (YES/NO)

9999999 Total XXX XXX

Note: The description provided for the Asset Category Description Column will be the category line number and description found in the instructions.

© 2014 National Association of Insurance Commissioners 205

ANNUAL STATEMENT BLANK – LIFE

SUPPLEMENTAL EXHIBITS AND SCHEDULESINTERROGATORIES

Detail Eliminated To Conserve Space

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

Detail Eliminated To Conserve Space

APRIL FILING

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

42. Will the Interest-Sensitive Life Insurance Products Report Forms be filed with the state of domicile and the NAIC by April 1? ......................................................

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

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

45. Will the Analysis of Annuity Operations by Lines of Business be filed with the state of domicile and the NAIC by April 1? ......................................................

46. Will the Analysis of Increase in Annuity Reserves During the Year be filed with the state of domicile and the NAIC by April 1? ......................................................

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

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

49. Will the confidential Actuarial Memorandum required by Actuarial Guideline XXXVIII 8D be filed with the state of domicile by April 30? ......................................................

50. Will the Supplemental XXX/AXXX Reinsurance Exhibit be filed with the state of domicile and the NAIC by April 1? ......................................................

AUGUST FILING

5051. Will Management’s Report of Internal Control Over Financial Reporting be filed with the state of domicile by August 1? ......................................................

Detail Eliminated To Conserve Space

© 2014 National Association of Insurance Commissioners 206

ANNUAL STATEMENT BLANK –FRATERNAL

SUPPLEMENTAL EXHIBITS AND SCHEDULESINTERROGATORIES

Detail Eliminated To Conserve Space

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

Detail Eliminated To Conserve Space

APRIL FILING

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

37. Will the Interest Sensitive Life Insurance Products Report be filed with the state of domicile and the NAIC by April 1? .............................................................

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

39. Will the Analysis of Annuity Operations by Lines of Business be filed with the state of domicile and with the NAIC by April 1? .............................................................

40. Will the Analysis of Increase in Annuity Reserves During the Year be filed with the state of domicile and with the NAIC by April 1? .............................................................

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

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

43. Will the confidential Actuarial Memorandum required by Actuarial Guideline XXXVIII 8D be filed with the state of domicile by April 30? .............................................................

44. Will the Supplemental XXX/AXXX Reinsurance Exhibit be filed with the state of domicile and the NAIC by April 1? .............................................................

AUGUST FILING

4445. Will Management’s Report of Internal Control over Financial Reporting be filed with the state of domicile by August 1? .............................................................

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© 2014 National Association of Insurance Commissioners 207