NAIC BLANKS (E) WORKING GROUP

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1 NAIC BLANKS (E) WORKING GROUP Blanks Agenda Item Submission Form CONTACT PERSON: TELEPHONE: ADDRESS: ON BEHALF OF: NAME: TITLE: AFFILIATION: ADDRESS: DATE: 06/3/06 Commissioner Nick Gerhart (IA) Chair Variable Annuities Issues (E) WG Iowa Insurance Division 63 Locust, 4 th Floor Des Moines, Iowa FOR NAIC USE ONLY Agenda Item # 06-7BWG MOD Year 07 Changes to Existing Reporting [ X ] New Reporting Requirement [ ] 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 /5/06 [ ] Rejected Date [ ] Deferred Date [ ] Other (Specify) BLANK(S) TO WHICH PROPOSAL APPLIES [ X ] ANNUAL STATEMENT [ X ] QUARTERLY STATEMENT [ X ] INSTRUCTIONS [ ] CROSSCHECKS [ X ] BLANK [ X ] Life and Accident & Health [ ] Property/Casualty [ ] Health [ X ] Separate Accounts [ X ] Fraternal [ ] Title [ ] Other Specify Anticipated Effective Date: Annual 07 IDENTIFICATION OF ITEM(S) TO CHANGE Delete the General Interrogatory, Part Questions 9. and 9. (4. and 4. if Fraternal) regarding variable annuities with guarantees and renumber the remaining interrogatory questions. Replace interrogatory with a variable annuities supplement. Add a question to the Supplemental Exhibits and Schedules Interrogatories for the supplement. Remove Line. from the Separate Accounts General Interrogatories. REASON, JUSTIFICATION FOR AND/OR BENEFIT OF CHANGE** The supplement, in combination with separate proposed changes to the Actuarial Memorandum, is designed to address the charge given to the Variable Annuities Issues Working (E) Working Group related to redesigning the annual statement disclosures applicable to variable annuities to add more meaningful information about the valuation of guaranteed liabilities. This change in disclosure was intended to provide better information regarding the risks associated with these obligations. Comment on Effective Reporting Date: Other Comments: NAIC STAFF COMMENTS ** This section must be completed on all forms. Revised 6/3/ National Association of Insurance Commissioners 59

2 ANNUAL STATEMENT INSTRUCTIONS LIFE AND FRATERNAL This supplement is to be filed on or before MarchApril. VARIABLE ANNUITIES SUPPLEMENT PARTS AND For variable annuities (VAs) with guaranteed benefits disclose the type(s) of guaranteed benefit(s), the number of contracts or certificates with those benefits, the amount of the benefit base related to each type of benefit, the net amount at risk for death benefits and the guaranteed annual payout for income and withdrawal benefits, the gross amount of the reserve for the guaranteed benefit(s), the portion of the contract/certificate account value related to contract/certificate funds in the General Account or the Separate Account and the percent of the guaranteed benefit reinsured. Type shall include a summary description of the type of benefit. Examples are provided in the table illustrated below. For those guaranteed benefits that include waiting periods before any benefit can be realized, include the length of the original waiting period in the description A separate line shall be created for each combination of and Living Benefit o See the illustration in the table below for an example. o For a category with only one guarantee, show None in the other column. Each contract / certificate shall be included in one and only one line o For a contract with multiple living benefits, determine the most appropriate classification. A separate chart shall be prepared for individual contracts and for group contracts with individual certificates. In each chart, show the amount of any reinsurance reserve credit being taken separately for treaties with affiliated captive reinsurers and for other reinsurers. For purposes of this supplement, a Living Benefit (GLB) is defined as a contract/certificate, agreement or rider in which the insurance entity guarantees specified payouts during a defined period which may include the lifetime of the insured(s). For VAs, these guaranteed payouts are typically made regardless of the performance of the contractual account value that is used to determine cash surrender values and/or withdrawal benefits. Column 3 Number of Individual (Part ) Contracts or Group (Part ) Certificates Column 4 Benefit Base For (Col ) Report the Benefit Base (defined in the contract/certificate) as of the valuation date as the basis for the guaranteed value. If no guarantee exists, enter 0. Column 5 Benefit Base For Living Benefit (GLB) (Col ) Report the Benefit Base (defined in the contract/certificate) as of the valuation date as the basis for the guaranteed value. If no guarantee exists, enter 0. Column 6 Net Amount at Risk For (Col ) Net Amount at Risk is defined as the greater of a) zero and b) the difference between the and the Account Value as of the valuation date. Report the sum of the NAR for all contracts/certificates. Column 7 Annual Income Amount For Living Benefit (GLB) (Col ) Report the total annual income/withdrawal benefits available if the income/withdrawal guarantees were elected on the valuation date. If no GLB/GMWB is available on the valuation date for a particular contract/certificate (e.g. due to a waiting period), use 0. Note, for GLB and GMWB previously elected, show the guaranteed amount based on the prior elections. For GMAB, use 0 since this is not an income benefit. Disclosures for GMAB shall be provided in the AG 43 Memorandum. 06 National Association of Insurance Commissioners 60

3 Column 8 Account Value General Account Column 9 Account Value Separate Account Column 0 for Benefits ( Less BasicBase Adjusted ) gross reserve for guarantees as defined in AG-43 or VM as applicable in excess of the base contract reserve. s calculated according to AG-43 and VM- are allocated to individual contracts or certificates following the guidance of Appendix 6 of AG-43 or Section 8 of VM-. Report in column 0 the excess of this per policy reserve over the base contract reserve. For base contract reserve, the company may use CSV or Base Basic Adjusted (defined in Appendix 3, A.3.D of AG-43 or Section 5, B.4. of VM-) for that contract or certificate. Column & Percentage of Benefits Reinsured Illustration: Show percentage of the Benefit ceded to all reinsurers. Type 3 Benefit Base 6 7 Account Value 0 Percentage of Benefits Reinsured for Death Benefit Living Benefit Number of Individual Contracts / Group Certificates For (Col ) For Living Benefit (GLB) (Col ) Net Amount at Risk For (Col ) Annual Income Amount For Living Benefit (GLB) (Col ) General Account Separate Account Benefits ( Less BasicBase Adjusted ) Death Benefit Living Benefit Max Anniversary Value (MAV)* GMAB - 0% of pre M 0 5.7M 0.7M 93.0M.5M 60% 40% 3% Roll-up GMIB prem w/0 yr waiting period 3 3.6M 34.6M.4M.4M 0 3.M.0M 00% 00% Greater of MAV & 5% Roll-up GMIB ROP, 0 yrs M 35.0M 3.0M 0M 0M 37.0M.0M 0% 0% Subtotal, M 69.6M 0.M.4M.7M 6.M 4.5M XXX XXX. credit from affiliated captive reinsurance. credit from other reinsurance 3. net of reinsurance 06 National Association of Insurance Commissioners 6

4 ANNUAL STATEMENT BLANK LIFE AND FRATERNAL VARIABLE ANNUITIES SUPPLEMENT For Year Ended December 3, 07 (To Be Filed by MarchApril ) NAIC Group Code NAIC Company Code Part Individual Type 3 Benefit Base 6 7 Account Value 0 Percentage of Benefits Reinsured for Number of Individual For For Living Benefit Net Amount at Risk For Annual Income Amount For Living Benefit Separate Benefits ( Less BasicBase Living Benefit Contracts (Col ) (GLB) (Col ) (Col ) (GLB) (Col ) General Account Account Adjusted ) Living Benefit Subtotal XXX XXX. credit from affiliated captive reinsurance. credit from other reinsurance 3. net of reinsurance 06 National Association of Insurance Commissioners 6

5 Part Group Contracts with Individual Certificates Type 3 Benefit Base 6 7 Account Value 0 Percentage of Benefits Reinsured Number of Group Certificates Living Benefit For (Col ) For Living Benefit (GLB) (Col ) Net Amount at Risk For (Col ) Annual Income Amount For Living Benefit (GLB) (Col ) General Account Separate Account for Benefits ( Less BasicBase Adjusted ) Living Benefit Subtotal XXX XXX. credit from affiliated captive reinsurance. credit from other reinsurance 3. net of reinsurance 06 National Association of Insurance Commissioners 63

6 ANNUAL STATEMENT INSTRUCTIONS LIFE PART LIFE INTERROGATORIES Detail Eliminated To Conserve Space 9. For variable annuities with guaranteed benefits, disclose the type(s) of guaranteed benefit(s), the amount of variable annuity account value related to the benefit(s), the gross amount of the reserve for the benefit(s), the location of the reserve in the Annual Statement, the portion of each benefit reinsured, and the amount of any reinsurance reserve credit being taken for the benefit(s). For contracts that include only one of the two forms, enter NONE in the appropriate column. For those guaranteed benefits that include waiting periods before any benefit can be realized, include the length of the waiting period in the description of the benefit type. In addition, identify the length of time remaining until the end of the waiting period and the amount of account value related to each remaining time period. For reserves calculated according to Actuarial Guideline XLIII, column 6 (gross reserve) of each row of tables in the interrogatory should be calculated using the reserve allocated to each contract by calculating the difference between the total reserve and the basic adjusted reserve, which would include any excess stochastic reserve. For Extra under Actuarial Guideline XLIII, the portion of the reserve calculated according to Actuarial Guideline XLIII held in the general account may be split between a reserve supporting the fixed account portion of the variable annuity and the reserve supporting the guaranteed benefits. The reserve supporting the guaranteed benefits may be reported in either the Annuities section or the Miscellaneous s section of Section 5. However, that reserve should be identified separately. Illustration: If the response to 9. is YES, complete the table for each type of guaranteed benefit. () () (3) (4) (5) (6) (7) (8) (9) () () (3) Death Benefit Max Anniversary Value (MAV) 3% Roll-up Greater of MAV and 3% Roll-up Living Benefit GMAB 0% of prem., 5 yr. waiting period GMIB prem., accum. at 3%, 0 yr. waiting period GMIB return of prem., 0 yr. Waiting period Waiting Period Remaining 5 years 4 years 9 years 8 years 9 years 8 years Account Value Related to Column 3 50 mil 50 mil 400 mil 75 mil 5 mil 00 mil 50 mil 50 mil 00 mil (4) Greater of MAV, 3% Roll-up, and 40% of the contract earnings None N/A N/A Related Account Value 400 million 00 million Gross Amount of Location of.5 million Exhibit 5 Portion Reinsured 60% death benefit 40% living benefit Reinsurance Credit. million 3.0 million Exhibit 5 00% 3.0 million 00 million None Exhibit 5 None None 500 million.0 million Exhibit 5 None None 06 National Association of Insurance Commissioners 64

7 09. Disclose the amount of reserves carried by the reporting entity because it has sold annuities with a claimant as payee and to the extent to which the reporting entity is liable for such amounts. Include only annuities for which the property and casualty insurer obtained a release of liability from the claimant as a result of the purchase of an annuity from the reporting entity. 09. Disclose the name and location of the insurance company (i.e., legal entity and not group) that purchased the annuities during the current year and the aggregate statement value of annuities purchased, to the extent that the aggregate value of those annuities equals or exceeds 50,000. Include only annuities for which the property and casualty insurer obtained a release of liability from the claimant as a result of the purchase of an annuity from the reporting entity.. If the response to. is YES, provide for the captive affiliate the company name, NAIC company code, domiciliary jurisdiction, reserve credit amount and the amounts supporting the reserve credit (letters of credit, trust agreements and other). Credit: Report the amount by which the aggregate reserve for life contracts (Exhibit 5), deposit-type contracts (Exhibit 7) and accident and health contracts (Exhibit 6) has been reduced on account of reinsurance with authorized companies. The amounts by company should be the same as those shown for life reinsurance ceded in Schedule S, Part 3, Section, Columns 9 and 4 and for accident and health reinsurance ceded in Schedule S, Part 3, Section, Columns 9, 0 and Ordinary Life Insurance (U.S. business Only) for the current year for Lines 3., 3. and 3.3 (prior to reinsurance assumed or ceded) U.S. business includes U.S. States, Territories and Possessions (composed of the 50 states, the District of Columbia, American Samoa, Guam, Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands). The method for determining which jurisdiction a contract or certificatepolicy is reported in should be the same method used for reporting on Schedule T. Include: Exclude: Term (whether full underwriting, limited underwriting, jet issue, short form app ) Whole Life (whether full underwriting, limited underwriting, jet issue, short form app ) Variable Life (with or without Secondary Guarantee) Universal Life (with or without Secondary Guarantee) Variable Universal Life (with or without Secondary Guarantee) Credit Life Simplified Issue/ Issue (if it can be separated) Worksite Individually Solicited Group Life Direct Response Final Expense Pre-need Home Service COLI/BOLI/CHOLI. Refer to the NAIC Valuation Manual for additional guidance on what policies should be included. 06 National Association of Insurance Commissioners 65

8 ANNUAL STATEMENT INSTRUCTIONS FRATERNAL PART FRATERNAL INTERROGATORIES Detail Eliminated To Conserve Space 4. For variable annuities with guaranteed benefits, disclose the type(s) of guaranteed benefit(s), the amount of variable annuity account value related to the benefit(s), the gross amount reserve for the benefit(s), the location of the reserve in the Annual Statement, the portion of each benefit reinsured, and the amount of any reinsurance reserve credit being taken for the benefit(s). For contracts that include only one of the two forms, enter None in the appropriate column. For those guaranteed benefits that include waiting periods before any benefit can be realized, include the length of the waiting period in the description of the benefit type. In addition, identify the length of time remaining until the end of the waiting period and the amount of account value related to each remaining time period. For reserves calculated according to Actuarial Guideline XLIII, column 6 (gross reserve) of each row of tables in the interrogatory should be calculated using the reserve allocated to each contract by calculating the difference between the total reserve and the basic adjusted reserve, which would include any excess stochastic reserve. For Extra under Actuarial Guideline XLIII, the portion of the reserve calculated according to Actuarial Guideline XLIII held in the general account may be split between a reserve supporting the fixed account portion of the variable annuity and the reserve supporting the guaranteed benefits. The reserve supporting the guaranteed benefits may be reported in either the Annuities section or the Miscellaneous s section of Section 5. However, that reserve should be identified separately. Illustration: If the response to 4. is YES, complete the table for each type of guaranteed benefit. () () (3) (4) (5) (6) (7) (8) (9) () () (3) Death Benefit Max Anniversary Value (MAV) 3% Roll-up Greater of MAV and 3% Roll-up Living Benefit GMAB 0% of prem., 5 yr. waiting period GMIB prem., accum. at 3%, 0 yr. waiting period GMIB return of prem., 0 yr. Waiting period Waiting Period Remaining 5 years 4 years 9 years 8 years 9 years 8 years Account Value Related to Column 3 50 mil 50 mil 400 mil 75 mil 5 mil 00 mil 50 mil 50 mil 00 mil (4) Greater of MAV, 3% Roll-up, and 40% of the contract earnings None N/A N/A Related Account Value 400 million 00 million Gross Amount of Location of.5 million Exhibit 5 Portion Reinsured 60% death benefit 40% living benefit Reinsurance Credit. million 3.0 million Exhibit 5 00% 3.0 million 00 million None Exhibit 5 None None 500 million.0 million Exhibit 5 None None 06 National Association of Insurance Commissioners 66

9 54. Disclose the amount of reserves carried by the reporting entity because it has sold annuities with a claimant as payee and to the extent to which the reporting entity is liable for such amounts. Include only annuities for which the property and casualty insurer obtained a release of liability from the claimant as a result of the purchase of an annuity from the reporting entity. 54. Disclose the name and location of the insurance company (i.e., legal entity and not group) that purchased the annuities during the current year and the aggregate statement value of annuities purchased, to the extent that the aggregate value of those annuities equals or exceeds 50,000. Include only annuities for which the property and casualty insurer obtained a release of liability from the claimant as a result of the purchase of an annuity from the reporting entity. 76. If there are multiple liens, they should be listed individually. 87. If the response to 87. is YES, provide for the captive affiliate the company name, NAIC company code, domiciliary jurisdiction, reserve credit amount and the amounts supporting the reserve credit (letters of credit, trust agreements and other). Credit: Report the amount by which the aggregate reserve for life contracts (Exhibit 5), deposit-type contracts (Exhibit 7) and accident and health contracts (Exhibit 6) has been reduced on account of reinsurance with authorized companies. The amounts by company should be the same as those shown for life reinsurance ceded in Schedule S, Part 3, Section, Columns 9 and 4 and for accident and health reinsurance ceded in Schedule S, Part 3, Section, Columns 9, 0 and Ordinary Life Insurance (U.S. business Only) for the current year for Lines 98., 98. and 98.3 (prior to reinsurance assumed or ceded) U.S. business includes U.S. States, Territories and Possessions (composed of the 50 states, the District of Columbia, American Samoa, Guam, Northern Mariana Islands, Puerto Rico and the U.S. Virgin Islands). The method for determining which jurisdiction a contract or certificatepolicy is reported in should be the same method used for reporting on Schedule T. Include: Exclude: Term (whether full underwriting, limited underwriting, jet issue, short form app ) Whole Life (whether full underwriting, limited underwriting, jet issue, short form app ) Variable Life (with or without Secondary Guarantee) Universal Life (with or without Secondary Guarantee) Variable Universal Life (with or without Secondary Guarantee) Credit Life Simplified Issue/ Issue (if it can be separated) Worksite Individually Solicited Group Life Direct Response Final Expense Pre-need Home Service COLI/BOLI/CHOLI. Refer to the NAIC Valuation Manual for additional guidance on what policies should be included. 06 National Association of Insurance Commissioners 67

10 ANNUAL STATEMENT BLANK LIFE GENERAL INTERROGATORIES PART LIFE INTERROGATORIES Detail Eliminated To Conserve Space 9. Does the reporting entity have variable annuities with guaranteed benefits? Yes [ ] No [ ] 9. If 9. is yes, complete the following table for each type of guaranteed benefit. Type Related Waiting Period Account Value Account Gross Amount Location of Portion Living Benefit Remaining Related to Col. 3 Values of Reinsured Reinsurance Credit 09. For reporting entities having sold annuities to another insurer where the insurer purchasing the annuities has obtained a release of liability from the claimant (payee) as the result of the purchase of an annuity from the reporting entity only: 09. Amount of loss reserves established by these annuities during the current year: 09. List the name and location of the insurance company purchasing the annuities and the statement value on the purchase date of the annuities. P&C Insurance Company and Location Statement Value on Purchase Date of Annuities (i.e., Present Value) 0. Do you act as a custodian for health savings accounts? Yes [ ] No [ ] 0. If yes, please provide the amount of custodial funds held as of the reporting date. 0.3 Do you act as an administrator for health savings accounts? Yes [ ] No [ ] 0.4 If yes, please provide the balance of the funds administered as of the reporting date.. Are any of the captive affiliates reported on Schedule S, Part 3, authorized reinsurers? Yes [ ] No [ ] NA [ ]. If the answer to. is yes, please provide the following: Company Name NAIC Company Code 3 Domiciliary Jurisdiction 4 Credit Assets Supporting Credit Letters of Credit Trust Agreements Other 3. Provide the following for individual ordinary life insurance* policies (U.S. business only) for the current year (prior to reinsurance assumed or ceded). 3. Direct Premium Written 3. Incurred Claims 3.3 Number of Covered Lives *Ordinary Life Insurance Includes Term (whether full underwriting, limited underwriting, jet issue, "short form app") Whole Life (whether full underwriting, limited underwriting, jet issue, "short form app") Variable Life (with or without secondary guarantee) Universal Life (with or without secondary guarantee) Variable Universal Life (with or without secondary guarantee) 06 National Association of Insurance Commissioners 68

11 ANNUAL STATEMENT BLANK LIFE SUPPLEMENTAL EXHIBITS AND SCHEDULES INTERROGATORIES The following supplemental reports are required to be filed as part of your statement filing unless specifically waived by the domiciliary state. However, in the event that your domiciliary state waives the filing requirement, your response of WAIVED 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. MARCH FILING Responses Will the Supplemental Compensation Exhibit be filed with the state of domicile by March?... Will the confidential Risk-based Capital Report be filed with the NAIC by March?.. 3. Will the confidential Risk-based Capital Report be filed with the state of domicile, if required, by March?.. 4. Will an actuarial opinion be filed by March?.. 5. Will the Variable Annuities Supplement be filed by March?.. APRIL FILING 565. Will Management s Discussion and Analysis be filed by April? Will the Life, Health & Annuity Guaranty Association Model Act Assessment Base Reconciliation Exhibit be filed with the state of domicile and the NAIC by April? Will the Adjustment Form (if required) be filed with the state of domicile and the NAIC by April? Will the Supplemental Investment Risks Interrogatories be filed by April?.. 5. Will the Variable Annuities Supplement be filed by April?.. JUNE FILING 90. Will an audited financial report be filed by June?.. 0. Will Accountants Letter of Qualifications be filed with the state of domicile and electronically with the NAIC by June?.. AUGUST FILING. Will the regulator-only (non-public) Communication of Internal Control Related Matters Noted in Audit be filed with the state of domicile and electronically with the NAIC (as a regulator-only non-public document) by August?.. 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. MARCH FILING 3. Will Schedule SIS (Stockholder Information Supplement) be filed with the state of domicile by March? Will the Medicare Supplement Insurance Experience Exhibit be filed with the state of domicile and the NAIC by March? Will the Trusteed Surplus Statement be filed with the state of domicile and the NAIC by March? Will the actuarial opinion on participating and non-participating policies as required in Interrogatories and to Exhibit 5 be filed with the state of domicile and electronically with the NAIC by March? Will the actuarial opinion on non-guaranteed elements as required in interrogatory #3 to Exhibit 5 be filed with the state of domicile and electronically with the NAIC by March? Will the actuarial opinion on X-Factors be filed with the state of domicile and electronically with the NAIC by March? Will the actuarial opinion on Separate Accounts Funding Minimum Benefit be filed with the state of domicile and electronically with the NAIC by March? Will the actuarial opinion on Synthetic Investment Contracts be filed with the state of domicile and electronically with the NAIC by March?.. 0. Will the Reasonableness of Assumptions Certification required by Actuarial Guideline XXXV be filed with the state of domicile and electronically with the NAIC by March?... Will the Reasonableness and Consistency of Assumptions Certification required by Actuarial Guideline XXXV be filed with the state of domicile and electronically with the NAIC by March?.. 3. Will the Reasonableness of Assumptions Certification for Implied Rate Method required by Actuarial Guideline XXXVI be filed with the state of domicile and electronically with the NAIC by March? Will the Reasonableness and Consistency of Assumptions Certification required by Actuarial Guideline XXXVI (Updated Average Market Value) be filed with the state of domicile and electronically with the NAIC by March? Will the Reasonableness and Consistency of Assumptions Certification required by Actuarial Guideline XXXVI (Updated Market Value) be filed 06 National Association of Insurance Commissioners 69

12 with the state of domicile and electronically with the NAIC by March? Will the C-3 RBC Certifications required under C-3 Phase I be filed with the state of domicile and electronically with the NAIC by March? Will the C-3 RBC Certifications required under C-3 Phase II be filed with the state of domicile and electronically with the NAIC by March?.. SUPPLEMENTAL EXHIBITS AND SCHEDULES INTERROGATORIES 78. Will the Actuarial Certifications Related to Annuity Nonforfeiture Ongoing Compliance for Equity Indexed Annuities be filed with the state of domicile and electronically with the NAIC by March? Will the actuarial opinion required by the Modified Annuity Model Regulation be filed with the state of domicile and electronically with the NAIC by March? Will the Actuarial Certifications Related to Hedging required by Actuarial Guideline XLIII be filed with the state of domicile and electronically with the NAIC by March? Will the Financial Officer Certification Related to Clearly Defined Hedging Strategy required by Actuarial Guideline XLIII be filed with the state of domicile and electronically with the NAIC by March? Will the Management Certification That the Valuation Reflects Management s Intent required by Actuarial Guideline XLIII be filed with the state of domicile and electronically with the NAIC by March? Will the Actuarial Certification Related to the s required by Actuarial Guideline XLIII be filed with the state of domicile and electronically with the NAIC by March? Will the Actuarial Certification regarding the use of 00 Preferred Class Tables required by the Model Regulation Permitting the Recognition of Preferred Mortality Tables for Use in Determining Minimum Liabilities be filed with the state of domicile and electronically with the NAIC by March? Will the Workers Compensation Carve-Out Supplement be filed by March? Will Supplemental Schedule O be filed with the state of domicile and the NAIC by March? Will the Medicare Part D Coverage Supplement be filed with the state of domicile and the NAIC by March? Will an approval from the reporting entity s state of domicile for relief related to the five-year rotation requirement for lead audit partner be filed electronically with the NAIC by March? Will an approval from the reporting entity s state of domicile for relief related to the one-year cooling off period for independent CPA be filed electronically with the NAIC by March? Will an approval from the reporting entity s state of domicile for relief related to the Requirements for Audit Committees be filed electronically with the NAIC by March? Will the confidential Regulatory Asset Adequacy Issues Summary (RAAIS) required by Actuarial Opinion and Memorandum Regulation (Model 8), Section 7A(5), be filed with the state of domicile by March 5?.. APRIL FILING 44. Will the Long-Term Care Experience Reporting Forms be filed with the state of domicile and the NAIC by April? Will the Interest-Sensitive Life Insurance Products Report Forms be filed with the state of domicile and the NAIC by April? Will the Credit Insurance Experience Exhibit be filed with the state of domicile and the NAIC by April? Will the Accident and Health Policy Experience Exhibit be filed by April? Will the Analysis of Annuity Operations by Lines of Business be filed with the state of domicile and the NAIC by April? Will the Analysis of Increase in Annuity s During the Year be filed with the state of domicile and the NAIC by April? Will the Supplemental Health Care Exhibit (Parts, and 3) be filed with the state of domicile and the NAIC by April? 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? Will the confidential Actuarial Memorandum required by Actuarial Guideline XXXVIII 8D be filed with the state of domicile by April 30? Will the Supplemental XXX/AXXX Reinsurance Exhibit be filed with the state of domicile and the NAIC by April?.. AUGUST FILING 55. Will Management s Report of Internal Control Over Financial Reporting be filed with the state of domicile by August?.. Explanation: Bar code: 06 National Association of Insurance Commissioners 70

13 ANNUAL STATEMENT BLANK FRATERNAL GENERAL INTERROGATORIES PART FRATERNAL INTERROGATORIES Detail Eliminated To Conserve Space 4. Does the reporting entity have variable annuities with guaranteed benefits? Yes [ ] No [ ] 4. If 4. yes, complete the following table for each type of guaranteed benefit. Type Living Benefit Waiting Period Remaining Account Value Related to Col. 3 Related Account Value Gross Amount of Location of Portion Reinsured Reinsurance Credit 54. For reporting entities having sold annuities to another insurer where the insurer purchasing the annuities has obtained a release of liability from the claimant (payee) as the result of the purchase of an annuity from the reporting entity only: 54. Amount of loss reserves established by these annuities during the current year? 54. List the name and location of the insurance company purchasing the annuities and the statement value on the purchase date of the annuities. P&C Insurance Company and Location Statement Value on Purchase Date of Annuities (i.e., Present Value) 65. Do you act as a custodian for health savings accounts? Yes [ ] No [ ] 65. If yes, please provide the amount of custodial funds held as of the reporting date Do you act as an administrator for health savings accounts? Yes [ ] No [ ] 65.4 If yes, please provide the balance of the funds administered as of the reporting date. 76. Does the reporting entity have outstanding assessments in the form of liens against policy benefits that have increased surplus? 76. If yes, what is the date(s) of the original lien and the total outstanding balance of liens that remain in surplus? Yes [ ] No [ ] Date Outstanding Lien Amount 06 National Association of Insurance Commissioners 7

14 ANNUAL STATEMENT BLANK FRATERNAL SUPPLEMENTAL EXHIBITS AND SCHEDULES INTERROGATORIES The following supplemental reports are required to be filed as part of your statement filing unless specifically waived by the domiciliary state. However, in the event that your state of domicile waives the filing requirement, your response of WAIVED 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. MARCH FILING. Will the Supplemental Compensation Exhibit be filed with the state of domicile by March?.... Will the confidential Risk-Based Capital Report be filed with the NAIC by March? Will the confidential Risk-Based Capital Report be filed with the state of domicile, if required, by March? Will an actuarial opinion be filed by March? Will the Variable Annuities Supplement be filed by March?... APRIL FILING 565. Will Management s Discussion and Analysis be filed by April? Will the Supplemental Investment Risks Interrogatories be filed by April? Will the Variable Annuities Supplement be filed by April?... JUNE FILING 78. Will an audited financial report be filed by June? Will Accountants Letter of Qualifications be filed with the state of domicile and electronically with the NAIC by June?... AUGUST FILING 90. Will the regulator-only (non-public) Communication of Internal Control Related Matters Noted in Audit be filed with the state of domicile and electronically with the NAIC (as a regulator-only non-public document) by August?... Response 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. MARCH FILING 0. Will the Medicare Supplement Insurance Experience Exhibit be filed with the state of domicile and the NAIC by March?.... Will the Trusteed Surplus Statement be filed with the state of domicile and the NAIC by March? Will the actuarial opinion on participating and non-participating policies as required in Interrogatories and to Exhibit 5 be filed with the state of domicile and electronically with the NAIC by March? Will the statement on non-guaranteed elements as required in Interrogatory #3 to Exhibit 5 be filed with the state of domicile and electronically with the NAIC by March? Will the actuarial opinion on X-Factors be filed with the state of domicile and electronically with the NAIC by March? Will the actuarial opinion on Separate Accounts Funding Minimum Benefit be filed with the state of domicile and electronically with the NAIC by March? Will the actuarial opinion on Synthetic Investment Contracts be filed with the state of domicile and electronically with the NAIC by March? Will the Reasonableness of Assumptions Certification required by Actuarial Guideline XXXV be filed with the state of domicile and electronically with the NAIC by March? Will the Reasonableness and Consistency of Assumptions Certification required by Actuarial Guideline XXXV be filed with the state of domicile and electronically with the NAIC by March? Will the Reasonableness of Assumptions Certification for Implied Rate Method required by Actuarial Guideline XXXVI be filed with the state of domicile and electronically with the NAIC by March? Will the Reasonableness and Consistency of Assumptions Certification required by Actuarial Guideline XXXVI (Updated Average Market Value) be filed with the state of domicile and electronically with the NAIC by March?.... Will the Reasonableness and Consistency of Assumptions Certification required by Actuarial Guideline XXXVI (Updated Market Value) be filed with the state of Will the C-3 RBC Certifications required under C-3 Phase I be filed with the state of domicile and electronically with the NAIC by March? Will the C-3 RBC Certifications required under C-3 Phase II be filed with the state of domicile and electronically with the NAIC by March? Will the Actuarial Certifications Related to Annuity Nonforfeiture Ongoing Compliance for Equity Indexed Annuities be filed with the state of domicile and electronically with the NAIC by March? 56. Will the actuarial opinion required by the Modified Annuity Model Regulation be filed with the state of domicile and electronically with the NAIC by March? National Association of Insurance Commissioners 7

15 67. Will the Actuarial Certifications Related to Hedging required by Actuarial Guideline XLIII be filed with the state of domicile and electronically with the NAIC by March? Will the Financial Officer Certification Related to Clearly Defined Hedging Strategy required by Actuarial Guideline XLIII be filed with the state of domicile and electronically with the NAIC by March? Will the Management Certification That the Valuation Reflects Management s Intent required by Actuarial Guideline XLIII be filed with the state of domicile and electronically with the NAIC by March? Will the Actuarial Certification Related to the s required by Actuarial Guideline XLIII be filed with the state of domicile and electronically with the NAIC by March?... SUPPLEMENTAL EXHIBITS AND SCHEDULES INTERROGATORIES 303. Will the Actuarial Certification regarding the use of 00 Preferred Class Tables required by the Model Regulation Permitting the Recognition of Preferred Mortality Tables for Use in Determining Minimum Liabilities be filed with the state of domicile and electronically with the NAIC by March? 33. Will the Medicare Part D Coverage Supplement be filed with the state of domicile and the NAIC by March? 333. Will an approval from the reporting entity s state of domicile for relief related to the five-year rotation requirement for lead audit partner be filed electronically with the NAIC by March? Will an approval from the reporting entity s state of domicile for relief related to the one-year cooling off period for independent CPA be filed electronically with the NAIC by March? Will an approval from the reporting entity s state of domicile for relief related to the Requirements for audit Committees be filed electronically with the NAIC by March? Will the confidential Regulatory Asset Adequacy Issues Summary (RAAIS) required by Actuarial Opinion and Memorandum Regulation (Model 8), Section 7A(5), be filed with the state of domicile by March 5?) APRIL FILING Will the Long-term Care Experience Reporting Forms be filed with the state of domicile and the NAIC by April? Will the Interest Sensitive Life Insurance Products Report be filed with the state of domicile and the NAIC by April? Will the Accident and Health Policy Experience Exhibit be filed by April? Will the Analysis of Annuity Operations by Lines of Business be filed with the state of domicile and with the NAIC by April? 404. Will the Analysis of Increase in Annuity s During the Year be filed with the state of domicile and with the NAIC by April? 44. Will the Supplemental Health Care Exhibit (Parts, and 3) be filed with the state of domicile and the NAIC by April? 443. 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? Will the confidential Actuarial Memorandum required by Actuarial Guideline XXXVIII 8D be filed with the state of domicile by April 30? Will the Supplemental XXX-AXXX Reinsurance Exhibit be filed with the state of domicile and the NAIC by April? AUGUST FILING Will Management s Report of Internal Control over Financial Reporting be filed with the state of domicile by August? Explanation: Bar code: 06 National Association of Insurance Commissioners 73

16 ANNUAL STATEMENT BLANK SEPARATE ACCOUNTS GENERAL INTERROGATORIES. Does the reporting entity have products with guarantees provided by the general account? Yes [ ] No [ ]. If yes, what is the current total maximum guarantee the general account would provide to the separate account?.3 Has the separate account collected amounts from the general account within the past five years related to separate account guarantees? Yes [ ] No [ ].43 If yes, provide detail on these guarantees paid by the general account: Year Amount.450 As of December 3, As of December 3, As of December 3, As of December 3, As of December 3, To compensate the general account for the risk taken, for any separate account products with general account guarantees, does the separate account remit risk charges to the general account related to separate account guarantees? Yes [ ] No [ ].65 If yes, identify the separate account products with risk charges that are remitted to the general account and whether the risk charge for that product is reviewed and opined upon: Product Identifier with Risk Charges Risk Charge Reviewed and Opined Upon 3 Name and Title of Individual Who Provided Opinion on Risk Charges.76 Provide detail on the risk charges paid to the general account related to separate account guarantees for the past five years: Year Amount.760 As of December 3, As of December 3, As of December 3, As of December 3, As of December 3, 03 W:\QA\BlanksProposals\06-7BWG_Modified.doc 06 National Association of Insurance Commissioners 74