ANNUAL STATEMENT OF THE PROTECTED CELL OF THE. For Reference Only. in the state of TO THE. Insurance Department OF THE STATE OF

Transcription

1 ANNUAL STATEMENT OF THE PROTECTED CELL OF THE in the state TO THE Insurance Department OF THE STATE OF FOR THE YEAR ENDED DECEMBER 1, 2008 PROPERTY AND CASUALTY, PROTECTED CELL National Association Insurance Commissioners

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3 PROPERTY AND CASUALTY COMPANIES PROTECTED CELL ASSOCIATION EDITION Affix Bar Code Above ANNUAL STATEMENT F the Year Ended December 1, 2008 OF THE CONDITION AND AFFAIRS OF THE NAIC Group Code, NAIC Company Code Employer's ID Number (Current Period) (Pri Period) Organized under the Laws, State Domicile Pt Entry Country Domicile Incpated/Organized Commenced Business Statuty Home Office, (Street and Number) (City Town, State and Zip Code) Main Administrative Office (Street and Number) (City Town, State and Zip Code) (Area Code) (Telephone Number) Mail Address, (Street and Number P.O. Box) (City Town, State and Zip Code) Primary Location Books and Recds (Street and Number) (City Town, State and Zip Code) (Area Code) (Telephone Number) Internet Web Site Address Statuty Statement Contact (Name) (Area Code) (Telephone Number) (Extension) ( Address) (Fax Number) DIRECTORS OR TRUSTEES State... County ss The ficers this repting entity being duly swn, each depose and say that they are the described ficers said repting entity, and that on the repting period stated above, all the herein described assets were the absolute property the said repting entity, free and clear from any liens claims thereon, except as herein stated, and that this statement, together with related exhibits, schedules and explanations therein contained, annexed referred to, is a full and true statement all the assets and liabilities and the condition and affairs the said repting entity as the repting period stated above, and its income and deductions therefrom f the period ended, and have been completed in accdance with the NAIC Annual Statement Instructions and Accounting Practices and Procedures manual except to the extent that: (1) state law may differ;, (2) that state rules regulations require differences in repting not related to accounting practices and procedures, accding to the best their infmation, knowledge and belief, respectively. Furtherme, the scope this attestation by the described ficers also includes the related cresponding electronic filing with the NAIC, when required, that is an exact copy (except f fmatting differences due to electronic filing) the enclosed statement. The electronic filing may be requested by various regulats in lieu in addition to the enclosed statement. (Signature) (Signature) (Signature) (Printed Name) (Printed Name) (Printed Name) (Title) (Title) (Title) a. Is this an iginal filing? Yes [ ] No [ ] b. If no: 1. State the amendment number Subscribed and swn to befe me 2. filed this day.., Number pages attached National Association Insurance Commissioners P/PCell

4 ASSETS Current Year Pri Year 1 2 Fair Basis Fair Basis 1. Bonds (Schedule D) 2. Stocks (Schedule D): 2.1 Preferred stocks 2.2 Common stocks. Mtgage loans on real estate (Schedule B). 4. Real estate (Schedule A): 4.1 Properties held f the production income (less $ encumbrances) 4.2 Properties held f sale (less $. encumbrances) 5. Cash ($, Schedule E-Part 1) and cash equivalents. ($, Schedule E Part 2).. 6. Sht-term investments (Schedule DA) Other invested assets (Schedule BA) 8. Receivables f securities 9. Aggregate write-ins f invested assets Subtotals cash and invested assets (Lines 1 to 9) Investment income due and accrued. 12. Net adjustment in assets and liabilities due to feign exchange rates 1. Aggregate write-ins f other than invested assets. 14. Lines 10 to 1 DETAILS OF WRITE-INS Summary remaining write-ins f Line 9 from overflow page Totals (Lines 0901 through 090 plus 0998) (Line 9 above) Summary remaining write-ins f Line 1 from overflow page Totals (Lines 101 through 10 plus 198) (Line 1 above) National Association Insurance Commissioners P/PCell 2

5 LIABILITIES, SURPLUS AND OTHER FUNDS 1 2 Current Year Pri Year 1. Funds held under securitization agreement 2. Losses. Loss adjustment expenses Fees payable Other expenses.. 6. Due to/from general account (net) 7. Unearned premiums 8. Net adjustments in assets and liabilities due to feign exchange rates 9. Payable f securities 10. Aggregate write-ins f liabilities. 11. Total liabilities (Lines 1 through 10). 12. Unrealized capital gain (loss). 1. Contractual adjustment 14. Aggregate write-in f surplus funds. 15. Total surplus (Lines 12 through 14) 16. Total liabilities and surplus (Lines 11 and 15) DETAILS OF WRITE-INS Summary remaining write-ins f Line 10 from overflow page Totals (Lines 1001 through 100 plus 1098) (Line 10 above) Summary remaining write-ins f Line 14 from overflow page Totals (Lines 1401 through 140 plus 1498) (Line 14 above) National Association Insurance Commissioners P/PCell

6 SUMMARY OF OPERATIONS 1 Current Year Revenues 1. Premiums earned. 2. Net investment income (Exhibit Net Investment Income, Line 17) Capital gains and losses (Exhibit Capital Gains (Losses), Line 10) Aggregate write-ins f other income 5. Totals (Lines 1 through 4) Expenses 6. Change in unpaid losses Change in unpaid losses securitized Loss adjustment expenses incurred Interest expense Fee expense Aggregate write-ins f other transfers from Protected Cell Totals (Lines 5 through 11) 1. Net gain (loss) from operations (Line 5 minus Line 12) SURPLUS ACCOUNT 14. Surplus, December 1, pri year Net gain from operations (Line 1) Surplus contributed (withdrawn) during year Aggregate write-ins f other gains and losses in surplus Surplus, December 1, current year (Page, Line 15) DETAILS OF WRITE-INS Summary remaining write-ins f Line 4 from overflow page Totals (Lines 0401 through 040 plus 0498) (Line 4 above) Summary remaining write-ins f Line 11 from overflow page Totals (Lines 1101 through 110 plus 1198) (Line 11 above) Summary remaining write-ins f Line 17 from overflow page Totals (Lines 1701 through 170 plus 1798) (Line 17 above) Pri Year National Association Insurance Commissioners P/PCell 4

7 CASH FLOW Cash from Operations 1 Current Year 2 Pri Year 1. Premiums collected net reinsurance. 2. Net investment income.. Miscellaneous income. 4. Total (Lines 1 through ). 5. Benefit and loss related payments. 6. Net transfers to Separate Accounts, Segregated Accounts and Protected Cell Accounts. 7. Commissions, expenses paid and aggregate write-ins f deductions.. 8. Dividends paid to policyholders.. 9. Federal and feign income taxes paid (recovered) net $. tax on capital gains (losses) 10. Total (Lines 5 through 9). 11. Net cash from operations (Line 4 minus Line 10). Cash from Investments 12. Proceeds from investments sold, matured repaid: 12.1 Bonds Stocks. 12. Mtgage loans Real estate Other invested assets Net gains (losses) on cash, cash equivalents and sht-term investments Miscellaneous proceeds Total investment proceeds (Lines 12.1 to 12.7) Cost investments acquired (long-term only): 1.1 Bonds. 1.2 Stocks. 1. Mtgage loans. 1.4 Real estate Other invested assets Miscellaneous applications 1.7 Total investments acquired (Lines 1.1 to 1.6) Net increase (decrease) in contract loans and premium notes 15. Net cash from investments (Line 12.8 minus Line 1.7 minus Line 14) Cash from Financing and Miscellaneous Sources 16. Cash provided (applied): 16.1 Surplus notes, capital notes Capital and paid in surplus, less treasury stock Browed funds Net deposits on deposit-type contracts and other insurance liabilities Dividends to stockholders Other cash provided (applied) Net cash from financing and miscellaneous sources (Lines 16.1 to 16.4 minus Line 16.5 plus Line 16.6) RECONCILIATION OF CASH,CASH EQUIVALENTS AND SHORT-TERM INVESTMENTS 18. Net change in cash, cash equivalents and sht-term investments (Line 11, plus Lines 15 and 17) Cash, cash equivalents and sht-term investments: 19.1 Beginning year End year (Line 18 plus Line 19.1) Note: Supplemental disclosures cash flow infmation f non-cash transactions: National Association Insurance Commissioners P/PCell 5

8 EXHIBIT OF NET INVESTMENT INCOME 1 2 Collected During Year Earned During Year 1. U. S. Government bonds. (a) 1.1 Bonds exempt from U. S. tax. (a) 1.2 Other bonds (unaffiliated)... (a) 1. Bonds affiliates (a) 2.1 Preferred stocks (unaffiliated) (b) Preferred stocks affiliates... (b) Common stocks (unaffiliated) 2.21 Common stocks affiliates.... Mtgage loans... (c) 4. Real estate.. (d).. 5. Contract loans Cash, cash equivalents and sht-term investments (e) 7. Derivative instruments.. (f) 8. Other invested assets 9. Aggregate write-ins f investment income. 10. Total gross investment income 11. Investment expenses. (g) Investment taxes, licenses and fees, excluding federal income taxes.. (g).. 1. Interest expense... (h) Depreciation on real estate and other invested assets (i) 15. Aggregate write-ins f deductions from investment income 16. Total deductions (Lines 11 through 15) 17. Net investment income (Line 10 minus Line 16) DETAILS OF WRITE-INS Summary remaining write-ins f Line 9 from overflow page Totals (Lines 0901 through 090) plus 0998 (Line 9, above) Summary remaining write-ins f Line 15 from overflow page Totals (Lines 1501 through 150) plus 1598 (Line 15, above) (a) (b) (c) (d) (e) (f) (g) (h) (i) Includes $ accrual discount less $ amtization premium and less $ paid f accrued interest on purchases. Includes $ accrual discount less $ amtization premium and less $ paid f accrued dividends on purchases. Includes $ accrual discount less $ amtization premium and less $ paid f accrued interest on purchases. Includes $ f company s occupancy its own buildings; and excludes $ interest on encumbrances. Includes $ accrual discount less $ amtization premium and less $ paid f accrued interest on purchases. Includes $ accrual discount less $ amtization premium. Includes $ investment expenses and $ investment taxes, licenses and fees, excluding federal income taxes, attributable to segregated and Separate Accounts. Includes $ interest on surplus notes and $ interest on capital notes. Includes $ depreciation on real estate and $ depreciation on other invested assets. EXHIBIT OF CAPITAL GAINS (LOSSES) Realized Gain (Loss) On Sales Maturity Other Realized Adjustments Total Realized Capital Gain (Loss) (Columns 1 + 2) Change in Unrealized Capital Gain (Loss) Change in Unrealized Feign Capital Gain (Loss) 1. Government bonds. 1.1 Bonds exempt from U. S. tax 1.2 Other bonds (unaffiliated). 1. Bonds affiliates Preferred stocks (unaffiliated) Preferred stocks affiliates 2.2 Common stocks (unaffiliated) 2.21 Common stocks affiliates. Mtgage loans 4. Real estate Contract loans. 6. Cash, cash equivalents and sht-term investments 7. Derivative instruments Other invested assets 9. Aggregate write-ins f capital gains (losses) 10. Total capital gains (losses) DETAILS OF WRITE-INS Summary remaining write-ins f Line 9 from overflow page Totals (Lines 0901 through 090) plus 0998 (Line 9, above) National Association Insurance Commissioners 6 P/PCell

9 GENERAL INTERROGATORIES 1. Does this statement contain any securities valued at book value instead fair value? Yes [ ] No [ ] 1.2 If yes, identify each type security (bonds, stock, etc.) and the aggregate amount each security type repted at book value. 1 2 Type Security Amount National Association Insurance Commissioners 7 P/PCell

10 Years in Which Premiums Were Earned and Losses Were Incurred SCHEDULE P ANALYSIS OF LOSSES AND LOSS EXPENSES SCHEDULE P PART 1 SUMMARY ($000 Omitted) Loss and Loss Expense Payments Defense and Cost Adjusting Salvage and Loss Containment and Other Subrogation Total Net Paid Payments Payments Payments Received (Cols ) Number Claims Repted Premium Earned 1. Pri Totals Defense and Cost Losses Unpaid Containment Unpaid Bulk + IBNR Bulk + IBNR Salvage and Subrogation Anticipated Total Net Losses and Expenses Unpaid Number Claims Outstanding Case Basis Case Basis Adjusting and Other Unpaid Totals Total Losses and Loss Expenses Incurred Loss and Loss Expense Percentage (Incurred/ Premiums Earned) Net Balance Sheet Nontabular Discount Reserves After Discount Loss Expenses Unpaid Loss Loss Expense Losses Unpaid National Association Insurance Commissioners 8 P/PCell

11 OVERFLOW PAGE FOR WRITE-INS National Association Insurance Commissioners 9 P/PCell

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13 SUMMARY INVESTMENT SCHEDULE NOT APPLICABLE TO PROTECTED CELL National Association Insurance Commissioners SI01 Summary Investment

14 SCHEDULE A VERIFICATION BETWEEN YEARS Real Estate 1. Book/adjusted carrying value, December 1 pri year 2. Cost acquired: 2.1 Actual cost at time acquisition (Part 2, Column 6). 2.2 Additional investment made after acquisition (Part 2, Column 9)... Current year change in encumbrances:.1 Totals, Part 1, Column Totals, Part, Column Total gain (loss) on disposals, Part, Column Deduct amounts received on disposals, Part, Column Total feign exchange change in book/adjusted carrying value: 6.1 Totals, Part 1, Column Totals, Part, Column Deduct current year s other than tempary impairment recognized: 7.1 Totals, Part 1, Column Totals, Part, Column Deduct current year s depreciation: 8.1 Totals, Part 1, Column Totals, Part, Column Book/adjusted carrying value at the end current period (Lines ). 10. Deduct total nonadmitted amounts 11. Statement value at end current period (Line 9 minus Line 10).. SCHEDULE B VERIFICATION BETWEEN YEARS Mtgage Loans 1. Book value/recded investment excluding accrued interest on mtgages owned, December 1 pri year 2. Cost acquired: 2.1 Actual cost at time acquisition (Part 2, Column 7) Additional investment made after acquisition (Part 2, Column 8)... _. Capitalized past due deferred interest and other:.1 Totals, Part 1, Column 12. _.2 Totals, Part, Column 11. _ 4. Accrual discount. 5. Unrealized valuation increase (decrease): 5.1 Totals, Part 1, Column Totals, Part, Column 8. _ 6. Total gain (loss) on disposals, Part, Column Deduct amounts received on disposals, Part, Column Deduct amtization premium and mtgage interest points and commitment fees 9. Total feign exchange change in book value/recded investment excluding accrued interest: 9.1 Totals, Part 1, Column Totals, Part, Column 1. _ 10. Deduct current year s other than tempary impairment recognized: 10.1 Totals, Part 1, Column _ 10.2 Totals, Part, Column _ 11. Book value/recded investment excluding accrued interest at end current period (Lines ). 12. Total valuation allowance. 1. Subtotal (Line 11 plus Line 12). 14. Total Deduct total nonadmitted amounts Statement value mtgages owned at end current period (Line 1 minus Line14) National Association Insurance Commissioners SI02 Summary Investment

15 SCHEDULE BA VERIFICATION BETWEEN YEARS Other Long-Term Invested Assets 1. Book/adjusted carrying value, December 1 pri year Cost acquired: 2.1 Actual cost at time acquisition (Part 2, Column 8) Additional investment made after acquisition (Part 2, Column 9).... Capitalized deferred interest and other:.1 Totals, Part 1, Column 16.2 Totals, Part, Column Accrual discount Unrealized valuation increase (decrease): 5.1 Totals, Part 1, Column Totals, Part, Column 9 6. Total gain (loss) on disposals, Part, Column Deduct amounts received on disposals, Part, Column Deduct amtization premium and depreciation. 9. Total feign exchange change in book/adjusted carrying value: 9.1 Totals, Part 1, Column Totals, Part, Column Deduct current year s other than tempary impairment recognized: 10.1 Totals, Part 1, Column Totals, Part, Column Book/adjusted carrying value at end current period (Lines ) 12. Deduct total nonadmitted amounts.. 1. Statement value at end current period (Line 11 minus Line 12). _ SCHEDULE D VERIFICATION BETWEEN YEARS Bonds and Stocks 1. Book/adjusted carrying value, December 1 pri year Cost bonds and stocks acquired, Column 7, Part.. Accrual discount Unrealized valuation increase (decrease): 4.1 Column 12, Part Column 15, Part 2, Section Column 1, Part 2, Section Column 11, Part Total gain (loss) on disposals, Column 19, Part Deduction consideration f bonds and stocks disposed, Column 7, Part 4 7. Deduct amtization premium Total feign exchange change in book/adjusted carrying value: 8.1 Column 15, Part Column 19, Part 2, Section Column 16, Part 2, Section Column 15, Part 4 9. Deduct current year s other than tempary impairment recognized: 9.1 Column 14, Part 1, 9.2 Column 17, Part 2, Section Column 14, Part 2, Section Column 1, Part Book/adjusted carrying value at end current period (Lines ) Deduct total nonadmitted amounts Statement value at end current period (Line 10 minus Line 11) National Association Insurance Commissioners SI0 Summary Investment

16 SCHEDULE D SUMMARY BY COUNTRY Long-Term Bonds and Stocks OWNED December 1 Current Year 1 Book/Adjusted Carrying 2 Fair Actual Cost 4 Par Bonds Description BONDS 1. United States... Governments 2. Canada. (Including all obligations guaranteed. Other Countries by governments) 4. Totals 5. United States... States, Territies and Possessions 6. Canada. (Direct and guaranteed) 7. Other Countries 8. Totals 9. United States... Political Subdivisions States, 10. Canada. Territies and Possessions 11. Other Countries (Direct and guaranteed) 12. Totals Special revenue and special assessment 1. United States... obligations and all non-guaranteed 14. Canada. obligations agencies and authities 15. Other Countries governments and their political subdivisions 16. Totals 17. United States... Public Utilities (unaffiliated) 18. Canada. 19. Other Countries 20. Totals 21. United States... Industrial and Miscellaneous and Credit Tenant 22. Canada. Loans (unaffiliated) 2. Other Countries 24. Totals Parent, Subsidiaries and Affiliates 25. Totals 26. Total Bonds PREFERRED STOCKS 27. United States... Public Utilities (unaffiliated) 28. Canada. 29. Other Countries 0. Totals 1. United States... Banks, Trust and Insurance Companies 2. Canada. (unaffiliated). Other Countries 4. Totals 5. United States... Industrial and Miscellaneous (unaffiliated) 6. Canada. 7. Other Countries 8. Totals Parent, Subsidiaries and Affiliates 9. Totals 40. Total Preferred Stocks COMMON STOCKS 41. United States... Public Utilities (unaffiliated) 42. Canada. 4. Other Countries 44. Totals 45. United States... Banks, Trust and Insurance Companies 46. Canada. (unaffiliated) 47. Other Countries 48. Totals 49. United States... Industrial and Miscellaneous (unaffiliated) 50. Canada. 51. Other Countries 52. Totals Parent, Subsidiaries and Affiliates 5. Totals 54. Total Common Stocks 55. Total Stocks 56. Total Bonds and Stocks National Association Insurance Commissioners SI04 Summary Investment

17 SCHEDULE D PART 1A SECTIONS 1 AND 2 NOT APPLICABLE TO PROTECTED CELL National Association Insurance Commissioners SI05 SI10

18 SCHEDULE DA VERIFICATION BETWEEN YEARS Sht-Term Investments 5 Investments in Parent, Subsidiaries and Affiliates 4 Other Sht-term Investment Assets (a) Mtgage Loans Bonds Total Book/adjusted carrying value, December 1 pri year 2. Cost sht-term investments acquired... Accrual discount 4. Unrealized valuation increase (decrease). 5. Total gain (loss) on disposals. 6. Deduct consideration received on disposals. 7. Deduct amtization premium. 8. Total feign exchange change in book/adjusted carrying value Deduct current year s other than tempary impairment recognized 10. Book adjusted carrying value at end current period (Lines ). 11. Deduct total nonadmitted amounts Statement value at end current period (Line 10 minus Line 11) (a) Indicate the categy such assets, f example, joint ventures, transptation equipment: National Association Insurance Commissioners SI11 Summary Investment

19 SCHEDULE DB PART A VERIFICATION BETWEEN YEARS Options, Caps, Flos and Insurance Futures Options Owned 1. Book value, December 1, pri year (Line 8, pri year). 2. Cost/Option Premium (Section 2, Column 7).. Increase/(Decrease) by Adjustment (Section 1, Column 12) plus (Section, Column 1) 4. Gain/(Loss) on Termination: 4.1 Recognized (Sec., Column 14). 4.2 Used to Adjust Basis Hedged Item (Section, Column 15).. 5. Consideration Received on Terminations (Section, Column 12). 6. Used to Adjust Basis on Open Contracts (Sec. 1, Column 1) Disposition Deferred Amount on Contracts Terminated in Pri Year: 7.1 Recognized Used to Adjust Basis Hedged Item. 8. Book value, December 1, current year (Lines ). SCHEDULE DB PART B VERIFICATION BETWEEN YEARS Options, Caps, Flos and Insurance Futures Options Written 1. Book value, December 1, pri year (Line 8, pri year) Consideration received (Section 2, Column 7).... Increase/(Decrease) by Adjustment (Section 1, Column 12) plus (Section, Column 1) 4. Gain/(Loss) on Termination: 4.1 Recognized (Section, Column 14) 4.2 Used to Adjust Basis (Section, Column 15) 5. Consideration Paid on Terminations (Section, Column 12) 6. Used to Adjust Basis on Open Contracts (Section 1, Column 1). 7. Disposition Deferred Amount on Contracts Terminated in Pri Year: 7.1 Recognized Used to Adjust Basis.. 8. Book value, December 1, current year National Association Insurance Commissioners Summary Investment SI12

20 SCHEDULE DB PART C VERIFICATION BETWEEN YEARS Swaps and Fwards 1. Book value, December 1, pri year (Line 8, pri year). 2. Cost (Consideration Received) (Section 2, Column 7). Increase/(Decrease) by Adjustment (Section 1, Column 12) plus (Section, Column 1) 4. Gain/(Loss) on Termination: 4.1 Recognized (Section, Column 14) 4.2 Used to Adjust Basis Hedged Item (Section, Column 15) Consideration Received ( Paid) on Terminations (Section, Column 12).. 6. Used to Adjust Basis Hedged Item on Open Contracts (Section 1, Column 1). 7. Disposition Deferred Amount on Contracts Terminated in Pri Year: 7.1 Recognized Used to Adjust Basis Hedged Item Book value, December 1, current year (Lines ). SCHEDULE DB PART D VERIFICATION BETWEEN YEARS Futures Contracts and Insurance Futures Contracts 1. Book value, December 1, pri year (Line 8, pri year) _ 2. Change in total Variation Margin on Open Contracts (Difference between years-section 1, Column 6)... _.1 Change in Variation Margin on Open Contracts Used to Adjust Basis Hedged Item (Section 1, Column 11).. _.2 Change in Variation Margin on Open Contracts Recognized (Difference between years-section 1, Column 10). _ 4.1 Variation Margin on Contracts Terminated During the Year (Section, Column 6) 4.2 Less: 4.21 Gain/(Loss) Recognized in Current Year (Section, Column 11) Gain/(Loss) Used to Adjust Basis Hedge (Section, Column 12) 4. Subtotal (Line 4.1 minus Line 4.2) _ 5.1 Net Additions to Cash Deposits (Section 2, Column 7) Less: Net Reductions to Cash Deposits (Sec., Column 9). 6. Subtotal (Lines ) _ 7. Disposition Gain / (Loss) on Contracts Terminated in Pri Year: 7.1 Recognized. 7.2 Used to Adjust Basis Hedged Item 8. Book value, December 1, current year (Lines ).. _ SCHEDULE DB PART E VERIFICATION Statement and Fair Open Contracts Statement 1. Part A, Section 1, Column Part B, Section 1, Column 10. Part C, Section 1, Column Part D, Section 1, Column Lines (1) - (2) + () + (4) 6. Part E, Section 1, Column 4 7. Part E, Section 1, Column 5 8. Lines (5) (6) (7) Fair 9. Part A, Section 1, Column Part B, Section 1, Column Part C, Section 1, Column Part D, Section 1, Column Lines (9) - (10) + (11) + (12) 14. Part E, Section 1, Column Part E, Section 1, Column Lines (1) - (14) - (15) National Association Insurance Commissioners Summary Investment SI1

21 SCHEDULE DB PART F SECTION 1 Replicated (Synthetic) Assets Open Replicated (Synthetic) Asset Components the Replicated (Synthetic) Asset Derivative Instruments Open Cash Instrument(s) Held NAIC Designation Other Description Fair Statement Fair CUSIP Description Fair Description Statement NAIC Designation Other Description Replication RSAT Number Description Totals xxx xxx xxx xxx National Association Insurance Commissioners SI14 Summary Investment

22 SCHEDULE DB PART F SECTION 2 Reconciliation Replicated (Synthetic) Assets Open First Quarter Second Quarter Third Quarter Fourth Quarter Year To Total Replicated (Synthetic) Assets Statement Number Positions Total Replicated (Synthetic) Assets Statement Number Positions Total Replicated (Synthetic) Assets Statement Number Positions Total Replicated (Synthetic) Assets Statement Number Positions Total Replicated (Synthetic) Assets Statement Number Positions 1. Beginning Inventy. 2. Add: Opened Acquired Transactions.... Add: Increases in Replicated Asset Statement.. xxx xxx xxx. xxx xxx 4. Less: Closed Disposed Transactions.. 5. Less: Positions Disposed f Failing Effectiveness Criteria Less: Decreases in Replicated (Synthetic) Asset Statement xxx xxx xxx xxx xxx 7. Ending Inventy National Association Insurance Commissioners SI15 Summary Investment

23 SCHEDULE E VERIFICATION BETWEEN YEARS (Cash Equivalents) Book/adjusted carrying value, December 1 pri year.. 2. Cost cash equivalents acquired. Accrual discount.. 4. Unrealized valuation increase (decrease) 5. Total gain (loss) on disposals 6. Deduct consideration received on disposals. 7. Deduct amtization premium. 8. Total feign exchange change in book/adjusted carrying value. 9. Deduct current year s other than tempary impairment recognized 10. Book/adjusted carrying value at end current period (Lines ). 11. Deduct total nonadmitted amounts 12. Statement value at end current period (Lines 10 minus Line 11) Total Bonds (a) Indicate the categy such investments, f example, joint ventures, transptation equipment. Other (a) National Association Insurance Commissioners SI16 Summary Investment

24 National Association Insurance Commissioners Investment E01 SCHEDULE A PART 1 Showing All Real Estate OWNED December 1 Current Year 1 2 Location Change in Book/Adjusted Carrying Less Encumbrances Description Property Code City 4 State Acquired Last Appraisal Actual Cost Amount Encumbrances Book/Adjusted Carrying Less Encumbrances Fair Less Encumbrances 11 Current Year s Depreciation 12 Current Year s Other Than Tempary Impairment Recognized 1 Current Year s Change in Encumbrances 14 Total Change in B./A.C.V. ( ) 15 Total Feign Change in B./A.C.V. Gross Income Earned Less Interest Incurred on Encumbrances Taxes, Repairs, and Expenses Incurred Totals

25 National Association Insurance Commissioners Investment E02 SCHEDULE A PART 2 Showing All Real Estate ACQUIRED and Additions Made During the Year 1 Location Description Property 2 City State Acquired Name Vend Actual Cost at Time Acquisition Amount Encumbrances Book/Adjusted Carrying Less Encumbrances Additional Investment Made After Acquisition Totals

26 National Association Insurance Commissioners Investment E0 SCHEDULE A PART Showing All Real Estate DISPOSED During the Year, Including Payments During the Final Year on Sales Under Contract 1 Location Change in Book/Adjusted Carrying Less Encumbrances Description Property 2 City State Disposal Name Purchaser Actual Cost Expended f Additions, Permanent Improvements and Changes in Encumbrances Book/ Adjusted Carrying Less Encumbrances Pri Year 9 Current Year s Depreciation 10 Current Year s Other Than Tempary Impairment Recognized 11 Current Year s Change in Encumbrances 12 Total Change in B./A.C.V. ( ) 1 Total Feign Change in B./A.C.V. Book/Adjusted Carrying Less Encumbrances Amounts Received During Year Feign Gain (Loss) on Disposal Realized Gain (Loss) on Disposal Total Gain (Loss) on Disposal Gross Income Earned Less Interest Incurred on Encumbrances Taxes, Repairs and Expenses Incurred Total

27 SCHEDULE B PART 1 Showing All Mtgage Loans OWNED December 1 Current Year 1 2 Location Change in Book /Recded Investment Last Appraisal Valuation Land and Buildings 1 Total Feign Change in Book Capitalized Deferred Interest and Other Current Year s Other than Tempary Impairment Recognized Current Year s (Amtization)/ Accretion Unrealized Valuation Increase (Decrease) Book / Recded Investment Excluding Accrued Interest Rate Interest Acquired Loan Type State City Loan Number Code Totals General Interrogaty: 1. Mtgages in good standing $ unpaid taxes $ interest due and unpaid. 2. Restructured mtgages $ unpaid taxes $ interest due and unpaid.. Mtgages with overdue interest over 90 days not in process feclosure $ unpaid taxes $ interest due and unpaid. 4. Mtgages in process feclosure $ unpaid taxes $ interest due and unpaid National Association Insurance Commissioners E04 Investment

28 SCHEDULE B PART 2 Showing All Mtgage Loans ACQUIRED During the Current Year 1 Location Land and Buildings 2 Additional Investment Made After Acquisition Actual Cost at Time Acquisition Loan Type Acquired Rate Interest State City Loan Number Totals National Association Insurance Commissioners E05 Investment

29 National Association Insurance Commissioners Investment E06 SCHEDULE B PART Showing All Mtgage Loans DISPOSED, Transferred Repaid During the Current Year 1 Location Change in Book /Recded Investment Loan Number 2 City State Loan Type Acquired Disposal Book /Recded Investment Excluding Accrued Interest Pri Year 8 Unrealized Valuation Increase (Decrease) 9 Current Year s (Amtization)/ Accretion 10 Current Year s Other Than Tempary Impairment Recognized 11 Capitalized Deferred Interest and Other 12 Total Change in Book ( ) 1 Total Feign Change in Book Book /Recded Investment Excluding Accrued Interest on Disposal Consideration Feign Gain (Loss) on Disposal Realized Gain (Loss) on Disposal Total Gain (Loss) on Disposal Totals

30 National Association Insurance Commissioners Investment E07 SCHEDULE BA PART 1 Showing Other Long-Term Invested Assets OWNED December 1 Current Year 1 2 Location Change in Book/Adjusted Carrying CUSIP Identification Name Description Code 4 City 5 State Name Vend General Partner NAIC Designation Originally Acquired Type and Strategy Actual Cost Fair Book/ Adjusted Carrying Less Encumbrances 1 Unrealized Valuation Increase (Decrease) 14 Current Year s (Depreciation) (Amtization)/ Accretion 15 Current Year s Other than Tempary Impairment Recognized 16 Capitalized Deferred Interest and Other 17 Total Feign Change in B./A.C.V. Investment Income Commitment f Additional Investment Percentage Ownership Totals

31 SCHEDULE BA PART 2 Showing Other Long-Term Invested Assets ACQUIRED December 1 Current Year 1 2 Location Percentage Ownership Amount Encumbrances Additional Investment Made After Acquisition Actual Cost at Time Acquisition Originally Acquired Type and Strategy Name Vend General Partner State City CUSIP Identification Name Description Totals National Association Insurance Commissioners E08 Investment

32 National Association Insurance Commissioners Investment E09 SCHEDULE BA PART Showing Other Long-Term Invested Assets DISPOSED, Transferred Repaid During the Current Year 1 2 Location Change in Book/Adjusted Carrying CUSIP Identification Name Description City 4 State Name Purchaser Nature Disposal Originally Acquired Disposal Book/Adjusted Carrying Less Encumbrances, Pri Year 9 Unrealized Valuation Increase (Decrease) 10 Current Year s (Depreciation) (Amtization)/ Accretion 11 Current Year s Other Than Tempary Impairment Recognized 12 Capitalized Deferred Interest and Other 1 Total Change in B./A.C.V. ( ) 14 Total Feign Change in B./A.C.V. Book/Adjusted Carrying Less Encumbrances on Disposal Consideration Feign Gain (Loss) on Disposal Realized Gain (Loss) on Disposal Total Gain (Loss) on Disposal Investment Income Totals

33 SCHEDULE D PART 1 Showing All Long-Term BONDS Owned December 1 Current Year 1 2 Codes 6 7 Fair Change in Book/Adjusted Carrying Interest s F o Amount Rec. During Year Acquired Maturity Admitted Amount Due Total Feign Change Current Year s Other Than Tempary Impairment Recognized Current Year s (Amtization)/ Accretion Unrealized Valuation Increase/ (Decrease) Book / Adjusted Carrying Rate Used To Obtain Fair e & Accrued When Paid Effective Rate Rate in B./A.C.V. Par Fair Actual Cost NAIC Designation Bond CHAR r CUSIP Identification Description Code i g n Total Bonds xxx xxx xxx xxx xxx xxx National Association Insurance Commissioners E10 Investment

34 National Association Insurance Commissioners Investment E11 SCHEDULE D PART 2 SECTION 1 Showing All PREFERRED STOCKS Owned December 1 Current Year 1 2 Codes Fair 11 Dividends Change in Book/Adjusted Carrying CUSIP Identification Description Code 4 F o r e i g n Number Shares Par Per Share Rate Per Share Book/ Adjusted Carrying 9 Rate per Share Used to Obtain Fair 10 Fair Actual Cost 12 Declared but Unpaid 1 Amount Received During Year 14 Nonadmitted Declared But Unpaid 15 Unrealized Valuation Increase/ (Decrease) 16 Current Year s (Amtization) Accretion 17 Current Year s Other Than Tempary Impairment Recognized 18 Total Change in B./A.C.V. ( ) 19 Total Feign Change in B./A.C.V. NAIC Designation Acquired Total Preferred Stocks

35 SCHEDULE D PART 2 SECTION 2 Showing all COMMON STOCKS Owned December 1 Current Year 1 2 Codes 5 6 Fair 9 Dividends Change in Book/Adjusted Carrying Current Year s Other Than Tempary Impairment Recognized Rate per Share Used to Obtain Fair F o NAIC Market Indicat (a) Total Feign Change in B./A.C.V Total Change in B./A.C.V. (1-14) Unrealized Valuation Increase/ (Decrease) Amount Received During Year e Acquired Nonadmitted Declared But Unpaid Declared but Unpaid Actual Cost Fair Book/Adjusted Carrying Number Shares Code CUSIP Identification Description g n r i Total Common Stocks Total Preferred and Common Stocks (a) F all common stocks bearing the NAIC market indicat "U" provide: the number such issues, the total $ value (included in Column 8) all such issues $ National Association Insurance Commissioners E12 Investment

36 SCHEDULE D PART Showing all Long-Term Bonds and Stocks ACQUIRED During Current Year 9 Paid f Accrued Interest and Dividends Par Actual Cost 6 Number Shares Stock 5 Name Vend Acquired Feign Description CUSIP Identification Totals National Association Insurance Commissioners E1 Investment

37 National Association Insurance Commissioners Investment E14 SCHEDULE D PART 4 Showing all Long-Term Bonds and Stocks SOLD, REDEEMED Otherwise DISPOSED OF During Current Year Change In Book/Adjusted Carrying CUSIP Identification 2 Description F o r e i g n Disposal Name Purchaser Number Shares Stock Consideration Par Actual Cost Pri Year Book/ Adjusted Carrying 11 Unrealized Valuation Increase/ (Decrease) 12 Current Year (Amtization)/ Accretion 1 Current Year s Other Than Tempary Impairment Recognized 14 Total Change in B./A.C.V. ( ) 15 Total Feign Change in B./A.C.V. Book/ Adjusted Carrying at Disposal Feign Gain (Loss) on Disposal Realized Gain (Loss) on Disposal Total Gain (Loss) on Disposal Bond Interest/ Stock Dividends Received During Year Maturity Totals xxx xxx

38 National Association Insurance Commissioners Investment E15 SCHEDULE D PART 5 Showing all Long-Term Bonds and Stocks ACQUIRED During Year and Fully DISPOSED OF During Current Year Change in Book/Adjusted Carrying CUSIP Identification Description Feign Acquired Name Vend Disposal Name Purchaser Par (Bonds) Number Shares (Stock) Actual Cost Consideration Book/ Adjusted Carrying at Disposal 12 Unrealized Valuation Increase/ (Decrease) 1 Current Year s (Amtization)/ Accretion 14 Current Year s Other Than Tempary Impairment Recognized 15 Total Change in B./A.C.V. ( ) 16 Total Feign Change in B./A.C.V. Feign Gain (Loss) on Disposal Realized Gain (Loss) on Disposal Total Gain (Loss) on Disposal Interest and Dividends Received During Year Paid f Accrued Interest and Dividends BONDS Subtotal Bonds STOCKS Subtotal-Stocks Totals

39 SCHEDULE D PART 6 SECTIONS 1 AND 2 NOT APPLICABLE TO PROTECTED CELL National Association Insurance Commissioners E16 Investment

40 National Association Insurance Commissioners Investment E17 SCHEDULE DA PART 1 Showing all SHORT-TERM INVESTMENTS Owned December 1 Current Year 1 Codes Change In Book/Adjusted Carrying 12 1 Interest 20 Description 2 Code F o r e i g n Acquired Name Vend Maturity Book/ Adjusted Carrying 8 Unrealized Valuation Increase/ (Decrease) 9 Current Year s (Amtization)/ Accretion 10 Current Year s Other Than Tempary Impairment Recognized 11 Total Feign Change in B./A.C.V. Par Actual Cost 14 Amount Due and Accrued Dec 1 Current Year on Bond Not in Default 15 Non-Admitted Due And Accrued 16 Rate 17 Effective Rate 18 When Paid 19 Amount Received During Year Paid f Accrued Interest TOTALS xxx xxx xxx xxx