TOI: 16.0 Workers Compensation Sub-TOI: Standard WC

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1 Adoption of NYCIRB Bulletins/ Filing at a Glance Companies: Company, Fidelity and Guaranty Insurance Company, Fidelity and Guaranty Insurance Underwriters, Inc., NIPPONKOA Insurance Company Ltd.,(U.S.Branch), The Charter Oak Fire Insurance Company, The Phoenix Insurance Company, The Travelers Indemnity Company, The Travelers Indemnity Company of America, The Travelers Indemnity Company Of Connecticut, Travelers Casualty and Surety Company, Travelers Casualty Insurance Company of America, Travelers Property Casualty Company of America, United States Fidelity and Guaranty Company SERFF Tr Num: TRVD State: New York TOI: 16.0 SERFF Status: Closed- Acknowledged for informational purposes State Tr Num: Sub-TOI: Standard WC Co Tr Num: State Status: Closed Filing Type: Form Reviewer(s): Elen Bard Author: Jane Swanson Disposition Date: 04/19/2011 Date Submitted: 04/08/2011 Disposition Status: Acknowledged for informational purposes Effective Date Requested (New): 10/01/2011 Effective Date (New): Effective Date Requested (Renewal): 10/01/2011 Effective Date (Renewal): General Information Project Name: Adoption of NYCIRB Bulletins Status of Filing in Domicile: Not Filed Project Number: Domicile Status Comments: Except NIPPONKOA - pending with this filing Reference Organization: NYCIRB Reference Number: 2262; 2263 Reference Title: New York & Employers Advisory Org. Circular: R.C. Bulletins 2262; Liability Manual 2263 Filing Status Changed: 04/19/2011 State Status Changed: 04/19/2011 Deemer Date: Created By: Karen Christiansen Submitted By: Karen Christiansen Corresponding Filing Tracking Number: Filing Description: In compliance with the insurance laws and regulations of your state, we are filing to adopt the following Commercial forms recently approved by your department for NYCIRB.

2 Adoption of NYCIRB Bulletins/ The NYCIRB bulletins that we are hereby adopting are Bulletins R.C and Your approval of this filing will be appreciated. Should you have any questions regarding this submission, please feel free to contact me at your convenience. Company and Contact Filing Contact Information Jane Swanson, Senior Regulatory Analyst 385 Washington Street [Phone] St. Paul, MN [FAX] Filing Company Information CoCode: State of Domicile: Illinois Company 385 Washington Street Group Code: 3548 Company Type: St. Paul, MN Group Name: State ID Number: (651) ext. [Phone] FEIN Number: Fidelity and Guaranty Insurance Company CoCode: State of Domicile: Iowa 385 Washington Street Group Code: 3548 Company Type: St. Paul, MN Group Name: State ID Number: (651) ext. [Phone] FEIN Number: Fidelity and Guaranty Insurance Underwriters, CoCode: State of Domicile: Wisconsin Inc. 385 Washington Street Group Code: 3548 Company Type: St. Paul, MN Group Name: State ID Number: (651) ext. [Phone] FEIN Number: NIPPONKOA Insurance Company CoCode: State of Domicile: New York Ltd.,(U.S.Branch) One Tower Square Group Code: 3219 Company Type: (860) ext. [Phone] FEIN Number:

3 Adoption of NYCIRB Bulletins/ The Charter Oak Fire Insurance Company CoCode: State of Domicile: Connecticut (860) ext. [Phone] FEIN Number: The Phoenix Insurance Company CoCode: State of Domicile: Connecticut (860) ext. [Phone] FEIN Number: The Travelers Indemnity Company CoCode: State of Domicile: Connecticut (860) ext. [Phone] FEIN Number: The Travelers Indemnity Company of America CoCode: State of Domicile: Connecticut Hartford, CT Group Name: State ID Number: (860) ext. [Phone] FEIN Number: The Travelers Indemnity Company Of CoCode: State of Domicile: Connecticut Connecticut (860) ext. [Phone] FEIN Number: Travelers Casualty and Surety Company CoCode: State of Domicile: Connecticut (860) ext. [Phone] FEIN Number: Travelers Casualty Insurance Company of CoCode: State of Domicile: Connecticut America

4 Adoption of NYCIRB Bulletins/ (860) ext. [Phone] FEIN Number: Travelers Property Casualty Company of CoCode: State of Domicile: Connecticut America (860) ext. [Phone] FEIN Number: United States Fidelity and Guaranty Company CoCode: State of Domicile: Connecticut (860) ext. [Phone] FEIN Number: Filing Fees Fee Required? Retaliatory? Fee Explanation: Per Company: No No No COMPANY AMOUNT DATE PROCESSED TRANSACTION # $0.00 Company Fidelity and Guaranty Insurance Company $0.00 Fidelity and Guaranty Insurance Underwriters, $0.00 Inc. NIPPONKOA Insurance Company $0.00 Ltd.,(U.S.Branch) The Charter Oak Fire Insurance Company $0.00 The Phoenix Insurance Company $0.00 The Travelers Indemnity Company $0.00 The Travelers Indemnity Company of America $0.00 The Travelers Indemnity Company Of $0.00

5 Adoption of NYCIRB Bulletins/ Connecticut Travelers Casualty and Surety Company $0.00 Travelers Casualty Insurance Company of $0.00 America Travelers Property Casualty Company of $0.00 America United States Fidelity and Guaranty Company $0.00 State Specific Speed-To-Market Field: enter code "98" for Speed-To-Market filings. Enter "0" for N/A.: 0 Terrorism Exclusion Field: enter code "46-01" for filings which includes forms, rates or rules for the Terrorism Exclusion. Enter "0" for N/A.: 0 Mold (Fungi, Bacteria, Virus) Exclusion Field: enter code "46-02" for filings which includes forms, rates or rules for the Mold Exclusion. Enter "0" for N/A.: 0 On the Rate/Rule Schedule Tab, the "Add Rate Data" button must be changed to "yes" for all rating rules and rate filings in order for the appropriate fields to be completed. Please enter "Yes" for filings with the rate data fields completed and "No" for all other filings.: No

6 Correspondence Summary Adoption of NYCIRB Bulletins/ Dispositions Status Created By Created On Date Submitted Acknowledge Elen Bard 04/18/ /19/2011 d for informational purposes

7 Disposition Adoption of NYCIRB Bulletins/ Disposition Date: 04/19/2011 Effective Date (New): Effective Date (Renewal): Status: Acknowledged for informational purposes Comment: Re: WC F, WC B, WC A Dear Jane Swanson: This refers to your April 8, 2011 submission of the captioned file. The adoption of the New York Compensation Insurance Rating Board's (NYCIRB) Bulletins R.C and R.C and the above captioned forms are acknowledged for informational purposes. Please note standard policy forms and endorsements identical to the ones previously filed by the NYCIRB and approved by the New York State Insurance Department (NYSID) will no longer require filing with the NYSID prior to use. Any such filings received will be noted in the records as acknowledged for informational purposes. Individual insurer policy forms and endorsements that deviate from the aforementioned standard forms including a change in the form identification number must be filed and approved by the NYSID. Very truly yours, Elen Bard Insurance Examiner Property Bureau (212) (tel.) (212) (fax) Ebard@ins.state.ny.us Rate data does NOT apply to filing.

8 Adoption of NYCIRB Bulletins/ Overall Rate Information for Multiple Company Filings Overall Percentage Rate Indicated For This Filing 0.000% Overall Percentage Rate Impact For This Filing 0.000% Effect of Rate Filing-Written Premium Change For This Program $0 Effect of Rate Filing - Number of Policyholders Affected 0

9 Adoption of NYCIRB Bulletins/ Schedule Schedule Item Schedule Item Status Public Access Supporting Document Explanatory Memorandum Yes Supporting Document Workers' Compensation and Employers' Yes Liability -Policy Limits Supporting Document Workers' Compensation and Employers' Yes Liability- Forms Supporting Document Workers' Compensation and Employers' Liability- Cancellation & Nonrenewal Yes

10 Adoption of NYCIRB Bulletins/ Supporting Document Schedules Satisfied - Item: Explanatory Memorandum Comments: Please refer to filing description Item Status: Status Date: Item Status: Status Date: Bypassed - Item: Workers' Compensation and Employers' Liability -Policy Limits Bypass Reason: NA - simple adoption filing only Comments: Item Status: Satisfied - Item: Workers' Compensation and Employers' Liability- Forms Comments: Adopting NYCIRB forms WC F; WC B; and WC A. Status Date: This filing does not include any proprietary endorsements. Item Status: Status Date: Bypassed - Item: Workers' Compensation and Employers' Liability- Cancellation & Nonrenewal Bypass Reason: NA - simple adoption filing only Comments:

SERFF Tracking Number: QBEC State: Oregon First Filing Company: QBE Insurance Corporation,... State Tracking Number: QBEC

SERFF Tracking Number: QBEC State: Oregon First Filing Company: QBE Insurance Corporation,... State Tracking Number: QBEC Filing at a Glance Companies: QBE Insurance Corporation, Praetorian Insurance Company, North Pointe Insurance Company ISO Market Segments - Hotels, SERFF Tr Num: QBEC-128112702 State: Oregon Motels and