*478000000* ANNUAL STATEMENT FOR THE YEAR ENDING DECEMBER, 0 OF THE CONDITION AND AFFAIRS OF THE Florida True Health, Inc. NAIC Group Code 0096, 0096 NAIC Company Code 478 Employer s ID Number 45-4088 (Current Period) (Prior Period) Organized under the Laws of Florida, State of Domicile or Port of Entry Florida Country of Domicile United States Licensed as business type: Life, Accident & Health [ ] Property/Casualty [ ] Hospital, Medical & Dental Service or Indemnity [ ] Dental Service Corporation [ ] Vision Service Corporation [ ] Health Maintenance Organization [ X ] Other [ ] Is HMO, Federally Qualified? Yes [ ] No [ X ] Incorporated/Organized /9/0 Commenced Business 07/09/0 Statutory Home Office 60 Kew Gardens Ave, Suite 00, Palm Beach Gardens, FL, 40 (Street and Number) (City, State, Country and Zip Code) Main Administrative Office 00 Stevens Drive (Street and Number) Philadelphia, PA, 9 5-97-8000 (City, State, Country and Zip Code) (Area Code) (Telephone Number) Mail Address 60 Kew Gardens Ave. Suite 00, Palm Beach Gardens, FL, 40 (Street and Number or P.O. Box) (City, State, Country and Zip Code) Primary Location of Books and Records Internet Web Site Address 00 Stevens Drive (Street and Number) Philadelphia, PA, 9, 5-97-8000 (City, State, Country and Zip Code) (Area Code) (Telephone Number) (Extension) www.fltruehealth.com Statutory Statement Contact Lori Ann Porrini, 5-86-85 (Name) (Area Code) (Telephone Number) (Extension) Lori.Porrini@amerihealthmercy.com 5-97-549 (E-Mail Address) (Fax Number) OFFICERS Name Title Name Title Dwight David Chenette #, President Debi Gavras #, Executive Director Steven Harvey Bohner #, Vice President and Treasurer Robert Howard Gilman Esquire #, Vice President and Secretary OTHER OFFICERS,, DIRECTORS OR TRUSTEES Robert Chris Doerr # Joyce Ann Kramzer # Steven Harvey Bohner # Anne Maureen Morrissey # State of County of Florida ss The officers of this reporting entity, being duly sworn, each depose and say that they are the described officers of said reporting entity, and that on the reporting period stated above, all of the herein described assets were the absolute property of the said reporting entity, free and clear from any liens or claims thereon, except as herein stated, and that this statement, together with related exhibits, schedules and explanations therein contained, annexed or referred to, is a full and true statement of all the assets and liabilities and of the condition and affairs of the said reporting entity as of the reporting period stated above, and of its income and deductions therefrom for the period ended, and have been completed in accordance with the NAIC Annual Statement Instructions and Accounting Practices and Procedures manual except to the extent that: () state law may differ; or, () that state rules or regulations require differences in reporting not related to accounting practices and procedures, according to the best of their information, knowledge and belief, respectively. Furthermore, the scope of this attestation by the described officers also includes the related corresponding electronic filing with the NAIC, when required, that is an exact copy (except for formatting differences due to electronic filing) of the enclosed statement. The electronic filing may be requested by various regulators in lieu of or in addition to the enclosed statement. Steven Harvey Bohner Vice President and Treasurer Robert Howard Gilman, Esquire Vice President and Secretary a. Is this an original filing? Yes [ X ] No [ ] Subscribed and sworn to before me this b. If no: day of February, 0. State the amendment number. Date filed. Number of pages attached Altyne Bowe, Notary Public December 0, 04
ASSETS Current Year Prior Year 4 Assets Nonadmitted Assets Net Admitted Assets (Cols. - ) Net Admitted Assets. Bonds (Schedule D) 0 0 0. Stocks (Schedule D):. Preferred stocks 0 0 0. Common stocks 0 0 0. Mortgage loans on real estate (Schedule B):. First liens 0 0. Other than first liens 0 0 4. Real estate (Schedule A): 4. Properties occupied by the company (less $ encumbrances) 0 0 4. Properties held for the production of income (less $ encumbrances) 0 0 4. Properties held for sale (less $ encumbrances) 0 0 5. Cash ($ 650,000, Schedule E-Part ), cash equivalents ($ 8,8,554, Schedule E-Part ) and short-term investments ($ 0, Schedule DA) 8,768,554 8,768,554 0 6. Contract loans (including $ premium notes) 0 0 7. Derivatives (Schedule DB) 0 0 8. Other invested assets (Schedule BA) 4,750,000 4,750,000 0 0 9. Receivables for securities 0 0 0. Securities lending reinvested collateral assets (Schedule DL) 0 0. Aggregate write-ins for invested assets,00,000,000,000 00,000 0. Subtotals, cash and invested assets (Lines to ) 54,88,554 5,750,000 9,068,554 0. Title plants less $ charged off (for Title insurers only) 0 0 4. Investment income due and accrued 0 0 5. Premiums and considerations: 5. Uncollected premiums and agents balances in the course of collection 0 0 5. Deferred premiums, agents balances and installments booked but deferred and not yet due (including $ earned but unbilled premiums) 0 0 5. Accrued retrospective premiums 0 0 6. Reinsurance: 6. Amounts recoverable from reinsurers 0 0 6. Funds held by or deposited with reinsured companies 0 0 6. Other amounts receivable under reinsurance contracts 0 0 7. Amounts receivable relating to uninsured plans 0 0 8. Current federal and foreign income tax recoverable and interest thereon 0 0 8. Net deferred tax asset 8,79 7,96 45,46 0 9. Guaranty funds receivable or on deposit 0 0 0. Electronic data processing equipment and software 9,877 9,877 0. Furniture and equipment, including health care delivery assets ($ ) 76,90 76,90 0 0. Net adjustment in assets and liabilities due to foreign exchange rates 0 0. Receivables from parent, subsidiaries and affiliates 0 0 4. Health care ($ ) and other amounts receivable 0 0 5. Aggregate write-ins for other than invested assets 6,4 6,4 0 0 6. Total assets excluding Separate Accounts, Segregated Accounts and Protected Cell Accounts (Lines to 5) 55,405,06 6,6,89 9,4,847 0 7. From Separate Accounts, Segregated Accounts and Protected Cell Accounts 0 0 8. Total (Lines 6 and 7) 55,405,06 6,6,89 9,4,847 0 DETAILS OF WRITE-INS 0. State Mandated Insolvency Protection Deposit 00,000 00,000 0. Surplus Note Receivable,000,000,000,000 0 0. 98. Summary of remaining write-ins for Line from overflow page 0 0 0 0 99. Totals (Lines 0 through 0 plus 98) (Line above),00,000,000,000 00,000 0 50. Leasehold Improvement,564,564 0 50. Prepaid Expenses 9,760 9,760 0 50. 598. Summary of remaining write-ins for Line 5 from overflow page 0 0 0 0 599. Totals (Lines 50 through 50 plus 598) (Line 5 above) 6,4 6,4 0 0
LIABILITIES, CAPITAL AND SURPLUS Covered Current Year Uncovered Total Prior Year 4 Total. Claims unpaid (less $ reinsurance ceded) 0 0. Accrued medical incentive pool and bonus amounts 0 0. Unpaid claims adjustment expenses 0 0 4. Aggregate health policy reserves, including the liability of $ for medical loss ratio rebate per the Public Health Service Act 0 0 5. Aggregate life policy reserves 0 0 6. Property/casualty unearned premium reserves 0 0 7. Aggregate health claim reserves 0 0 8. Premiums received in advance 0 0 9. General expenses due or accrued 80,669 80,669 0 0. Current federal and foreign income tax payable and interest thereon (including $ on realized capital gains (losses)) 5,84 5,84 0 0. Net deferred tax liability 0 0. Ceded reinsurance premiums payable 0 0. Amounts withheld or retained for the account of others 0 0. Remittances and items not allocated 0 0 4. Borrowed money (including $ current) and interest thereon $ (including $ current) 0 0 5. Amounts due to parent, subsidiaries and affiliates 8,49,05 8,49,05 0 6. Derivatives 0 0 7. Payable for securities 0 0 8. Payable for securities lending 0 0 9. Funds held under reinsurance treaties (with $ authorized reinsurers, $ unauthorized reinsurers and ($ certified reinsurers) 0 0 0. Reinsurance in unauthorized and certified ($ ) companies 0 0. Net adjustments in assets and liabilities due to foreign exchange rates 0 0. Liability for amounts held under uninsured plans 0 0. Aggregate write-ins for other liabilities (including $ current) 0 0 0 0 4. Total liabilities (Lines to ) 8,956,688 0 8,956,688 0 5. Aggregate write-ins for special surplus funds XXX XXX 0 0 6. Common capital stock XXX XXX 0 7. Preferred capital stock XXX XXX 0 8. Gross paid in and contributed surplus XXX XXX 55,855,000 0 9. Surplus notes XXX XXX 0 0. Aggregate write-ins for other than special surplus funds XXX XXX 0 0. Unassigned funds (surplus) XXX XXX (45,567,84) 0. Less treasury stock, at cost:. shares common (value included in Line 6 $ ) XXX XXX 0. shares preferred (value included in Line 7 $ ) XXX XXX 0. Total capital and surplus (Lines 5 to minus Line ) XXX XXX 0,87,59 0 4. Total liabilities, capital and surplus (Lines 4 and ) XXX XXX 9,4,847 0 DETAILS OF WRITE-INS 0. 0. 0. 98. Summary of remaining write-ins for Line from overflow page 0 0 0 0 99. Totals (Lines 0 through 0 plus 98) (Line above) 0 0 0 0 50. XXX XXX 50. XXX XXX 50. XXX XXX 598. Summary of remaining write-ins for Line 5 from overflow page XXX XXX 0 0 599. Totals (Lines 50 through 50 plus 598) (Line 5 above) XXX XXX 0 0 00. XXX XXX 00. XXX XXX 00. XXX XXX 098. Summary of remaining write-ins for Line 0 from overflow page XXX XXX 0 0 099. Totals (Lines 00 through 00 plus 098) (Line 0 above) XXX XXX 0 0
STATEMENT OF REVENUE AND EXPENSES Current Year Uncovered Total Prior Year Total. Member Months XXX 0 0. Net premium income (including $ 0 non-health premium income) XXX 0 0. Change in unearned premium reserves and reserve for rate credits XXX 0 4. Fee-for-service (net of $ medical expenses) XXX 0 5. Risk revenue XXX 0 6. Aggregate write-ins for other health care related revenues XXX 0 0 7. Aggregate write-ins for other non-health revenues XXX 0 0 8. Total revenues (Lines to 7) XXX 0 0 Hospital and Medical: 9. Hospital/medical benefits 0 0. Other professional services 0. Outside referrals 0. Emergency room and out-of-area 0. Prescription drugs 0 4. Aggregate write-ins for other hospital and medical 0 0 0 5. Incentive pool, withhold adjustments and bonus amounts 0 6. Subtotal (Lines 9 to 5) 0 0 0 Less: 7. Net reinsurance recoveries 0 8. Total hospital and medical (Lines 6 minus 7) 0 0 0 9. Non-health claims (net) 0 0. Claims adjustment expenses, including $ 0 cost containment expenses 0 0. General administrative expenses 9,56,50 0. Increase in reserves for life and accident and health contracts (including $ increase in reserves for life only) 0 0. Total underwriting deductions (Lines 8 through ) 0 9,56,50 0 4. Net underwriting gain or (loss) (Lines 8 minus ) XXX (9,56,50) 0 5. Net investment income earned (Exhibit of Net Investment Income, Line 7) 7,04 0 6. Net realized capital gains (losses) less capital gains tax of $ 0 7. Net investment gains (losses) (Lines 5 plus 6) 0 7,04 0 8. Net gain or (loss) from agents or premium balances charged off [(amount recovered $ ) (amount charged off $ )] 0 0 9. Aggregate write-ins for other income or expenses 0 0 0 0. Net income or (loss) after capital gains tax and before all other federal income taxes (Lines 4 plus 7 plus 8 plus 9) XXX (9,59,6) 0. Federal and foreign income taxes incurred XXX 5,84 0. Net income (loss) (Lines 0 minus ) XXX (9,55,00) 0 DETAILS OF WRITE-INS 060. XXX 060. XXX 060. XXX 0698. Summary of remaining write-ins for Line 6 from overflow page XXX 0 0 0699. Totals (Lines 060 through 060 plus 0698) (Line 6 above) XXX 0 0 070. XXX 070. XXX 070. XXX 0798. Summary of remaining write-ins for Line 7 from overflow page XXX 0 0 0799. Totals (Lines 070 through 070 plus 0798) (Line 7 above) XXX 0 0 40. 40. 40. 498. Summary of remaining write-ins for Line 4 from overflow page 0 0 0 499. Totals (Lines 40 through 40 plus 498) (Line 4 above) 0 0 0 90. 90. 90. 998. Summary of remaining write-ins for Line 9 from overflow page 0 0 0 999. Totals (Lines 90 through 90 plus 998) (Line 9 above) 0 0 0 4
STATEMENT OF REVENUE AND EXPENSES (Continued) Current Year Prior Year CAPITAL & SURPLUS ACCOUNT. Capital and surplus prior reporting year 0 0 4. Net income or (loss) from Line (9,55,00) 0 5. Change in valuation basis of aggregate policy and claim reserves 0 6. Change in net unrealized capital gains (losses) less capital gains tax of $ 0 7. Change in net unrealized foreign exchange capital gain or (loss) 0 8. Change in net deferred income tax 8,79 0 9. Change in nonadmitted assets (6,6,90) 0 40. Change in unauthorized and certified reinsurance 0 0 4. Change in treasury stock 0 0 4. Change in surplus notes 0 0 4. Cumulative effect of changes in accounting principles 0 44. Capital Changes: 44. Paid in 0 0 44. Transferred from surplus (Stock Dividend) 0 44. Transferred to surplus 0 45. Surplus adjustments: 45. Paid in 55,855,000 0 45. Transferred to capital (Stock Dividend) 0 0 45. Transferred from capital 0 46. Dividends to stockholders 0 47. Aggregate write-ins for gains or (losses) in surplus 0 0 48. Net change in capital and surplus (Lines 4 to 47) 0,87,59 0 49. Capital and surplus end of reporting year (Line plus 48) 0,87,59 0 DETAILS OF WRITE-INS 470. 470. 470. 4798. Summary of remaining write-ins for Line 47 from overflow page 0 0 4799. Totals (Lines 470 through 470 plus 4798) (Line 47 above) 0 0 5
Cash from Operations CASH FLOW Current Year Prior Year. Premiums collected net of reinsurance 0 0. Net investment income 7,04 0. Miscellaneous income 0 0 4. Total (Lines through ) 7,04 0 5. Benefit and loss related payments 0 0 6. Net transfers to Separate Accounts, Segregated Accounts and Protected Cell Accounts 0 7. Commissions, expenses paid and aggregate write-ins for deductions 8,68,88 0 8. Dividends paid to policyholders 0 9. Federal and foreign income taxes paid (recovered) net of $ tax on capital gains (losses) 0 0 0. Total (Lines 5 through 9) 8,68,88 0. Net cash from operations (Line 4 minus Line 0) (8,60,084) 0 Cash from Investments. Proceeds from investments sold, matured or repaid:. Bonds 0 0. Stocks 0 0. Mortgage loans 0 0.4 Real estate 0 0.5 Other invested assets 0 0.6 Net gains or (losses) on cash, cash equivalents and short-term investments 0 0.7 Miscellaneous proceeds 0 0.8 Total investment proceeds (Lines. to.7) 0 0. Cost of investments acquired (long-term only):. Bonds 0 0. Stocks 0 0. Mortgage loans 0 0.4 Real estate 0 0.5 Other invested assets 4,750,000 0.6 Miscellaneous applications,000,000 0.7 Total investments acquired (Lines. to.6) 5,750,000 0 4. Net increase (decrease) in contract loans and premium notes 0 0 5. Net cash from investments (Line.8 minus Line.7 minus Line 4) (5,750,000) 0 Cash from Financing and Miscellaneous Sources 6. Cash provided (applied): 6. Surplus notes, capital notes 0 0 6. Capital and paid in surplus, less treasury stock 55,855,000 0 6. Borrowed funds 0 0 6.4 Net deposits on deposit-type contracts and other insurance liabilities 0 6.5 Dividends to stockholders 0 0 6.6 Other cash provided (applied) 7,64,69 0 7. Net cash from financing and miscellaneous sources (Lines 6. to 6.4 minus Line 6.5 plus Line 6.6) 6,9,69 0 RECONCILIATION OF CASH, CASH EQUIVALENTS AND SHORT-TERM INVESTMENTS 8. Net change in cash, cash equivalents and short-term investments (Line, plus Lines 5 and 7) 8,768,555 0 9. Cash, cash equivalents and short-term investments: 9. Beginning of year 0 0 9. End of year (Line 8 plus Line 9.) 8,768,555 0 6
7 ANALYSIS OF OPERATIONS BY LINES OF BUSINESS Comprehensive (Hospital & Medical) 4 Medicare Dental Vision Other Total Supplement Only Only Other Health Non-Health. Net premium income 0 0 0 0 0 0 0 0 0 0. Change in unearned premium reserves and reserve for rate credit 0. Fee-for-service (net of $ medical expenses) 0 XXX 4. Risk revenue 0 XXX 5. Aggregate write-ins for other health care related revenues 0 0 0 0 0 0 0 0 0 XXX 6. Aggregate write-ins for other non-health care related revenues 0 XXX XXX XXX XXX XXX XXX XXX XXX 0 7. Total revenues (Lines to 6) 0 0 0 0 0 0 0 0 0 0 8. Hospital/medical benefits 0 XXX 9. Other professional services 0 XXX 0. Outside referrals 0 XXX. Emergency room and out-of-area 0 XXX. Prescription drugs 0 XXX. Aggregate write-ins for other hospital and medical 0 0 0 0 0 0 0 0 0 XXX 4. Incentive pool, withhold adjustments and bonus amounts 0 XXX 5. Subtotal (Lines 8 to 4) 0 0 0 0 0 0 0 0 0 XXX 6. Net reinsurance recoveries 0 XXX 7. Total hospital and medical (Lines 5 minus 6) 0 0 0 0 0 0 0 0 0 XXX 8. Non-health claims (net) 0 XXX XXX XXX XXX XXX XXX XXX XXX 0 9. Claims adjustment expenses including $ 0 cost containment expenses 0 0. General administrative expenses 9,56,50 9,56,50. Increase in reserves for accident and health contracts 0 XXX. Increase in reserves for life contracts 0 XXX XXX XXX XXX XXX XXX XXX XXX. Total underwriting deductions (Lines 7 to ) 9,56,50 0 0 0 0 0 0 9,56,50 0 0 4. Net underwriting gain or (loss) (Line 7 minus Line ) (9,56,50) 0 0 0 0 0 0 (9,56,50) 0 0 DETAILS OF WRITE-INS 050. XXX 050. XXX 050. XXX 0598. Summary of remaining write-ins for Line 5 from overflow page 0 0 0 0 0 0 0 0 0 XXX 0599. Totals (Lines 050 through 050 plus 0598) (Line 5 above) 0 0 0 0 0 0 0 0 0 XXX 060. XXX XXX XXX XXX XXX XXX XXX XXX 060. XXX XXX XXX XXX XXX XXX XXX XXX 060. XXX XXX XXX XXX XXX XXX XXX XXX 0698. Summary of remaining write-ins for Line 6 from overflow page 0 XXX XXX XXX XXX XXX XXX XXX XXX 0 0699. Totals (Lines 060 through 060 plus 0698) (Line 6 above) 0 XXX XXX XXX XXX XXX XXX XXX XXX 0 0. XXX 0. XXX 0. XXX 98. Summary of remaining write-ins for Line from overflow page 0 0 0 0 0 0 0 0 0 XXX 99. Totals (Lines 0 through 0 plus 98) (Line above) 0 0 0 0 0 0 0 0 0 XXX 5 6 Federal Employees Health Benefit Plan 7 Title XVIII Medicare 8 Title XIX Medicaid 9 0
Part - Premiums Part - Claims Incurred During the Year Part A - Claims Liability Part B - Analysis of Claims Pt C - Sn A - Paid Claims - Comp Pt C - Sn A - Paid Claims - MS Pt C - Sn A - Paid Claims - DO Pt C - Sn A - Paid Claims - VO Pt C - Sn A - Paid Claims - FE Pt C - Sn A - Paid Claims - XV Pt C - Sn A - Paid Claims - XI 8, 9, 0,, -HM, -MS, -DO, -VO, -FE, -XV, -XI
Pt C - Sn A - Paid Claims - OT Pt C - Sn A - Paid Claims - GT Pt C - Sn B - Incurred Claims - Comp Pt C - Sn B - Incurred Claims - MS Pt C - Sn B - Incurred Claims - DO Pt C - Sn B - Incurred Claims - VO Pt C - Sn B - Incurred Claims - FE Pt C - Sn B - Incurred Claims - XV Pt C - Sn B - Incurred Claims - XI Pt C - Sn B - Incurred Claims - OT Pt C - Sn B - Incurred Claims - GT -OT, -GT, -HM, -MS, -DO, -VO, -FE, -XV, -XI, -OT, -GT
Part C - Sn C - Claims Expense Ratio Co Part C - Sn C - Claims Expense Ratio MS Part C - Sn C - Claims Expense Ratio DO Part C - Sn C - Claims Expense Ratio VO Part C - Sn C - Claims Expense Ratio FE Part C - Sn C - Claims Expense Ratio XV Part C - Sn C - Claims Expense Ratio XI Part C - Sn C - Claims Expense Ratio OT Part C - Sn C - Claims Expense Ratio GT Aggregate Reserve for A&H Contracts -HM, -MS, -DO, -VO, -FE, -XV, -XI, -OT, -GT,
UNDERWRITING AND INVESTMENT EXHIBIT PART - ANALYSIS OF EXPENSES Claim Adjustment Expenses 4 5 Cost Containment Expenses Other Claim Adjustment Expenses General Administrative Expenses Investment Expenses Total. Rent ($ for occupancy of own building) 0 07,95 07,95. Salaries, wages and other benefits,469,7,469,7. Commissions (less $ ceded plus $ assumed) 0 4. Legal fees and expenses,406,009,406,009 5. Certifications and accreditation fees 0 6. Auditing, actuarial and other consulting services,66,94,66,94 7. Traveling expenses 05,995 05,995 8. Marketing and advertising 4,690 4,690 9. Postage, express and telephone,09,09 0. Printing and office supplies 8,65 8,65. Occupancy, depreciation and amortization 80,4 80,4. Equipment 6, 6,. Cost or depreciation of EDP equipment and software 8,68 8,68 4. Outsourced services including EDP, claims, and other services 4, 4, 5. Boards, bureaus and association fees 9,69 9,69 6. Insurance, except on real estate 0 0 7. Collection and bank service charges,858,858 8. Group service and administration fees 0 9. Reimbursements by uninsured plans 0 0. Reimbursements from fiscal intermediaries 0. Real estate expenses 0. Real estate taxes 0. Taxes, licenses and fees:. State and local insurance taxes 69 69. State premium taxes 0 0. Regulatory authority licenses and fees 0 0.4 Payroll taxes 5,988 5,988.5 Other (excluding federal income and real estate taxes) 0 0 4. Investment expenses not included elsewhere 0 5. Aggregate write-ins for expenses 0 0 97,09 0 97,09 6. Total expenses incurred (Lines to 5) 0 0 9,56,50 0 (a) 9,56,50 7. Less expenses unpaid December, current year 80,669 80,669 8. Add expenses unpaid December, prior year 0 0 0 0 0 9. Amounts receivable relating to uninsured plans, prior year 0 0 0 0 0 0. Amounts receivable relating to uninsured plans, current year 0. Total expenses paid (Lines 6 minus 7 plus 8 minus 9 plus 0) 0 0 8,74,85 0 8,74,85 DETAILS OF WRITE-INS 50. Miscellaneous expenses 0,57 0,57 50. Purchased services 86,574 86,574 50. 0 0 598. Summary of remaining write-ins for Line 5 from overflow page 0 0 0 0 0 599. Totals (Line 50 through 50 + 598) (Line 5 above) 0 0 97,09 0 97,09 (a) Includes management fees of $ to affiliates and $ to non-affiliates. 4
EXHIBIT OF NET INVESTMENT INCOME Collected During Year Earned During Year. U.S. Government bonds (a). Bonds exempt from U.S. tax (a). Other bonds (unaffiliated) (a). Bonds of affiliates (a) 0. Preferred stocks (unaffiliated) (b) 0. Preferred stocks of affiliates (b) 0. Common stocks (unaffiliated) 0. Common stocks of affiliates 0. Mortgage loans (c) 4. Real estate (d) 5. Contract loans 6. Cash, cash equivalents and short-term investments (e) 7,04 7,04 7. Derivative instruments (f) 8. Other invested assets 9. Aggregate write-ins for investment income 0 0 0. Total gross investment income 7,04 7,04. Investment expenses (g). Investment taxes, licenses and fees, excluding federal income taxes (g). Interest expense (h) 4. Depreciation on real estate and other invested assets (i) 5. Aggregate write-ins for deductions from investment income 0 6. Total deductions (Lines through 5) 0 7. Net investment income (Line 0 minus Line 6) 7,04 DETAILS OF WRITE-INS 090. 090. 090. 0998. Summary of remaining write-ins for Line 9 from overflow page 0 0 0999. Totals (Lines 090 through 090) plus 0998 (Line 9 above) 0 0 50. 50. 50. 598. Summary of remaining write-ins for Line 5 from overflow page 0 599. Totals (Lines 50 through 50) plus 598 (Line 5 above) 0 (a) Includes $ accrual of discount less $ amortization of premium and less $ 0 paid for accrued interest on purchases. (b) Includes $ accrual of discount less $ amortization of premium and less $ 0 paid for accrued dividends on purchases. (c) Includes $ 0 accrual of discount less $ 0 amortization of premium and less $ paid for accrued interest on purchases. (d) Includes $ for company s occupancy of its own buildings; and excludes $ interest on encumbrances. (e) Includes $ accrual of discount less $ amortization of premium and less $ paid for accrued interest on purchases. (f) Includes $ accrual of discount less $ amortization of premium. (g) Includes $ investment expenses and $ investment taxes, licenses and fees, excluding federal income taxes, attributable to segregated and Separate Accounts. (h) Includes $ interest on surplus notes and $ interest on capital notes. (i) Includes $ depreciation on real estate and $ depreciation on other invested assets. EXHIBIT OF CAPITAL GAINS (LOSSES) Realized Gain (Loss) On Sales or Maturity Other Realized Adjustments Total Realized Capital Gain (Loss) (Columns + ) 4 Change in Unrealized Capital Gain (Loss) 5 Change in Unrealized Foreign Exchange Capital Gain (Loss). U.S. Government bonds 0. Bonds exempt from U.S. tax 0. Other bonds (unaffiliated) 0. Bonds of affiliates 0 0 0 0 0. Preferred stocks (unaffiliated) 0 0 0 0 0. Preferred stocks of affiliates 0 0 0 0 0. Common stocks (unaffiliated) 0 0 0 0 0. Common stocks of affiliates 0 0 0 0 0. Mortgage loans 0 0 0 0 0 4. Real estate 0 0 0 0 5. Contract loans 0 6. Cash, cash equivalents and short-term investments 0 0 0 7. Derivative instruments 0 8. Other invested assets 0 0 0 0 0 9. Aggregate write-ins for capital gains (losses) 0 0 0 0 0 0. Total capital gains (losses) 0 0 0 0 0 DETAILS OF WRITE-INS 090. 090. 090. 0998. Summary of remaining write-ins for Line 9 from overflow page 0 0 0 0 0 0999. Totals (Lines 090 through 090) plus 0998 (Line 9 above) 0 0 0 0 0 5
EXHIBIT OF NONADMITTED ASSETS Current Year Total Nonadmitted Assets Prior Year Total Nonadmitted Assets Change in Total Nonadmitted Assets (Col. - Col. ). Bonds (Schedule D) 0 0 0. Stocks (Schedule D):. Preferred stocks 0 0 0. Common stocks 0 0 0. Mortgage loans on real estate (Schedule B):. First liens 0 0 0. Other than first liens 0 0 0 4. Real estate (Schedule A): 4. Properties occupied by the company 0 0 0 4. Properties held for the production of income 0 0 0 4. Properties held for sale 0 0 0 5. Cash (Schedule E-Part ), cash equivalents (Schedule E-Part ) and short-term investments (Schedule DA) 0 0 0 6. Contract loans 0 0 0 7. Derivatives (Schedule DB) 0 0 0 8. Other invested assets (Schedule BA) 4,750,000 0 (4,750,000) 9. Receivables for securities 0 0 0 0. Securities lending reinvested collateral assets (Schedule DL) 0 0 0. Aggregate write-ins for invested assets,000,000 0 (,000,000). Subtotals, cash and invested assets (Lines to ) 5,750,000 0 (5,750,000). Title plants (for Title insurers only) 0 0 0 4. Investment income due and accrued 0 0 0 5. Premiums and considerations: 5. Uncollected premiums and agents balances in the course of collection 0 0 0 5. Deferred premiums, agents balances and installments booked but deferred and not yet due 0 0 0 5. Accrued retrospective premiums 0 0 0 6. Reinsurance: 6. Amounts recoverable from reinsurers 0 0 0 6. Funds held by or deposited with reinsured companies 0 0 0 6. Other amounts receivable under reinsurance contracts 0 0 0 7. Amounts receivable relating to uninsured plans 0 0 0 8. Current federal and foreign income tax recoverable and interest thereon 0 0 0 8. Net deferred tax asset 7,96 0 (7,96) 9. Guaranty funds receivable or on deposit 0 0 0 0. Electronic data processing equipment and software 0 0 0. Furniture and equipment, including health care delivery assets 76,90 0 (76,90). Net adjustment in assets and liabilities due to foreign exchange rates 0 0 0. Receivables from parent, subsidiaries and affiliates 0 0 0 4. Health care and other amounts receivable 0 0 0 5. Aggregate write-ins for other than invested assets 6,5 0 (6,5) 6. Total assets excluding Separate Accounts, Segregated Accounts and Protected Cell Accounts (Lines to 5) 6,6,90 0 (6,6,90) 7. From Separate Accounts, Segregated Accounts and Protected Cell Accounts 0 0 0 8. Total (Lines 6 and 7) 6,6,90 0 (6,6,90) DETAILS OF WRITE-INS 0. Surplus Note Receivable,000,000 (,000,000) 0. 0. 98. Summary of remaining write-ins for Line from overflow page 0 0 0 99. Totals (Lines 0 through 0 plus 98) (Line above),000,000 0 (,000,000) 50. Leasehold Improvements,565 (,565) 50. Prepaid Expenses 9,760 (9,760) 50. 598. Summary of remaining write-ins for Line 5 from overflow page 0 0 0 599. Totals (Lines 50 through 50 plus 598) (Line 5 above) 6,5 0 (6,5) 6
EXHIBIT - ENROLLMENT BY PRODUCT TYPE FOR HEALTH BUSINESS ONLY Source of Enrollment Prior Year. Health Maintenance Organizations 0. Provider Service Organizations 0. Preferred Provider Organizations 0 4. Point of Service 0 5. Indemnity Only 0 First Quarter Total Members at End of 6 4 5 Current Year Second Quarter Third Quarter Current Year Member Months 6. Aggregate write-ins for other lines of business 0 0 0 0 0 0 7. Total 0 0 0 0 0 0 DETAILS OF WRITE-INS 060. 060. 060. 7 0698. Summary of remaining write-ins for Line 6 from overflow page 0 0 0 0 0 0 0699. Totals (Lines 060 through 060 plus 0698) (Line 6 above) 0 0 0 0 0 0
NOTES TO FINANCIAL STATEMENTS. Summary of Significant Accounting Policies A. Accounting Practices Florida True Health, Inc. (the Company) prepares its statutory financial statements in accordance with the accounting practices prescribed or permitted by the Florida Office of Insurance Regulation (OIR). The Florida OIR recognizes only statutory accounting practices prescribed or permitted by the State of Florida for determining and reporting the financial condition and results of operations of an insurance company, and for determining its solvency under the Florida Insurance Law. The National Association of Insurance Commissioners (the NAIC) Accounting Practices and Procedures manual (NAIC SAP) has been adopted as a component of prescribed or permitted practices by the State of Florida The state has adopted certain prescribed accounting practices that differ from those found in NAIC SAP. Specifically, investments in administrative and management service entities and other healthcare providers shall not exceed 50 percent of admitted assets. The Commissioner of Insurance has the right to permit other specific practices that deviate from prescribed practices. A reconciliation of the Company s net income and capital and surplus between NAIC SAP and practices prescribed and permitted by the State of Florida is shown below: State of Domicile 0 0 NET INCOME () Florida True Health, Inc. state basis (Page 4, Line, Columns & ) Florida $ (9,55,00) $ () State Prescribed Practices that increase/(decrease) NAIC SAP () State Permitted Practices that increase/(decrease) NAIC (4) NAIC SAP(--=4) Florida $ (9,55,00) $ SURPLUS (5)Florida True Health, Inc. Company state basis (Page, Line, Columns & 4) Florida $ 0,87,59 $ (6) State Prescribed Practices that increase/(decrease) NAIC SAP: Other invested asset Florida $ 4,750,000 (7) State Permitted Practices that increase/(decrease) NAIC SAP: (8) NAIC SAP(5-6-7=8) Florida $ 45,07,59 $ B. Use of Estimates in the Preparation of the Financial Statements The preparation of statutory financial statements in conformity with accounting practices prescribed or permitted by the Florida OIR requires management to make estimates and assumptions that affect the amounts reported in the statutory financial statements and accompanying notes. Some of the more significant estimates include income taxes. Actual results could differ from those estimates. C. Accounting Policy The Company uses the following accounting policies: Cash and Cash Equivalents Cash and cash equivalents consist of all highly liquid investments with an original maturity of three months or less. Cash equivalents totaled $8,8,554 at December, 0. Other Invested Assets The Company accounts for its investments in subsidiaries, controlled and affiliated entities in accordance with Statement of Statutory Accounting Principles (SSAP) No. 97, Investments in Subsidiary, Controlled and Affiliated Entities. Fixed Assets Furniture and leasehold improvements are designated as nonadmitted assets and are charged directly to capital and surplus. Electronic Data Processing (EDP) equipment exceeding three percent of statutory capital and surplus for the most recently filed statement with the State of Florida (adjusted to exclude EDP equipment) are designated as nonadmitted assets and are charged directly to surplus. Depreciation is calculated on a straight-line basis over the estimated useful life of the assets, which ranges from three to seven years. Leasehold improvements are amortized on a straight-line basis over the shorter of the remaining lease term or the estimated useful life of the asset. Maintenance and repairs are charged to operations when incurred. Regulation The NAIC adopted RBC standards for health organizations, including HMOs, that are designed to identify weakly capitalized companies by comparing each company s adjusted capital and surplus to its required capital 5
NOTES TO FINANCIAL STATEMENTS and surplus (RBC ratio). The RBC ratio is designed to reflect the risk profile of the Company. Within certain ratio changes, regulators have increasing authority to take action as the RBC ratio decreases. There are four levels of regulatory action, ranging from requiring insurers to submit a comprehensive plan to the state insurance commissioner to requiring the state insurance commissioner to place the insurer under regulatory control. As of December, 0, the State of Florida has not yet adopted these standards.. Accounting Changes and Corrections of Errors. Business Combinations and Goodwill 4. Discontinued Operations 5. Investments A. Mortgage Loans, including Mezzanine Real Estate Loans B. Debt Restructuring C. Reverse Mortgages D. Loan-Backed Securities. Loan Back Securities.. Recognized Other-than-Temporary Impairment. Present Value of Cash Flows 4. All impaired securities (fair value is less than cost or amortized cost) for which an other-than temporary impairment has not been recognized. E. Repurchase Agreements F. Real Estate G. Low-income housing tax credits (LHITC) 6. Joint Ventures, Partnerships and Limited Liability Companies On December, 0 the Company acquired a 40% interest in Prestige Health Choice, LLC (Prestige), a provider service network that provides access to comprehensive medical services for Florida Medicaid beneficiaries. The total consideration paid for the Company s investment in Prestige amounted to $4,750,000. This investment is reported as an other invested asset on the statutory statement of admitted assets and has been non-admitted for statutory reporting purposes. 7. Investment Income Interest and dividend income from cash and cash equivalents are included in investment income on the statutory statement of revenues and expenses. 8. Derivative Instruments 9. Income Taxes The Company is a Florida Insurance Company that is subject to state and federal income tax. Deferred income tax assets and liabilities represent the expected future federal tax consequences of temporary differences generated by statutory accounting. Deferred income tax assets and liabilities are computed by means of identifying temporary differences, which are measured using a balance sheet approach whereby statutory and tax-basis balance sheet are compared. Changes in deferred tax assets and liabilities are recognized as a separate component of changes in capital and surplus except to the extent allocated changes in unrealized gains and losses. Changes in deferred tax assets and liabilities allocated to unrealized gains and losses are netted against the related changes in unrealized gains and losses and are also reported as a separate component of the change in capital and surplus. In November 0, the NAIC issued SSAP No. 0, Income Taxes, A Replacement of SSAP No. 0R and SSAP No. 0. This statement establishes statutory accounting principles for current and deferred federal and foreign income 5.
NOTES TO FINANCIAL STATEMENTS taxes and current state income taxes. This statement supersedes SSAP No. 0, Income Taxes and SSAP No. 0R, Income Taxes, a temporary replacement of SSAP No.0, which expired on December, 0. SSAP No. 0 has: ) restricted the ability to use the years/5 percent of surplus admission rule to those reporting entities that meet the modified RBC ratio threshold, ) changed the recognition threshold for recording tax contingency reserves from a probable liability standard to a more-likely-than-not liability standard, ) required the disclosure of tax planning strategies that relate to reinsurance, and 4) required consideration of reversal patterns of deferred tax assets (DTAs) and deferred tax liabilities (DTLs) in determining the extent to which DTLs could offset DTAs on the statutory balance sheet. SSAP No. 0 became authoritative guidance for accounting and reporting of income taxes for statutory financial statements beginning January, 0. Because the Company commenced operations after the effective date of this guidance, there was no cumulative effect of adopting this standard. State income tax expense in the amount of $69 is recorded in general administrative expenses in the statutory statement of revenues and expenses for the year ended December, 0. The components of the net deferred tax asset/(liability) at December, 0 and 0 are as follows: //0 () Ordinary () Capital () Total (a) Gross Deferred Tax Assets $,455,99 - - (b) Statutory Valuation Allowance Adjustments,7,540 - - (c) Adjusted Gross Deferred Tax Assets (a - b) 8,79 - - (d) Deferred Tax Assets Nonadmitted 7,96 - - Subtotal Net Admitted Deferred Tax Asset (c - d) 45,46 - - (e) (f) Deferred Tax Liabilities - - - (g) Net Admitted Deferred Tax Asset/(Net Deferred $ 45,46 - - //0 (4) Ordinary (5) Capital (6) Total (a) Gross Deferred Tax Assets $ - - - (b) Statutory Valuation Allowance Adjustments - - - (c) Adjusted Gross Deferred Tax Assets (a - b) - - - (d) Deferred Tax Assets Nonadmitted - - - Subtotal Net Admitted Deferred Tax Asset (c - d) - - - (e) (f) Deferred Tax Liabilities - - - (g) Net Admitted Deferred Tax Asset/(Net Deferred $ - - - Change (7) Ordinary (8) Capital (9) Total (a) Gross Deferred Tax Assets $,455,99 - - (b) Statutory Valuation Allowance Adjustments,7,540 - - (c) Adjusted Gross Deferred Tax Assets (a - b) 8,79 - - (d) Deferred Tax Assets Nonadmitted 7,96 - - Subtotal Net Admitted Deferred Tax Asset (c - d) 45,46 - - (e) (f) Deferred Tax Liabilities - - - (g) Net Admitted Deferred Tax Asset/(Net Deferred $ 45,46 - - 5.
NOTES TO FINANCIAL STATEMENTS //0 () Ordinary () Capital () (Col +) Total Admission Calculation Components SSAP No. 0 - (a) Federal Income Taxes Paid In Prior Years Recoverable Through Loss Carrybacks $ - (b) (c) (d) Adjusted Gross Deferred Tax Assets Expected To Be Realized (Excluding The Amount Of Deferred Tax Assets From (a) above) After Application of the Threshold Limitation. (The Lesser of (b) and (b) Below) 45,46 - Adjusted Gross Deferred Tax Assets Expected to be Realized Following the Balance Sheet Date 45,46 - Adjusted Gross Deferred Tax Assets Allowed per Limitation Threshold Adjusted Gross Deferred Tax Assets (Excluding The Amount Of Deferred Tax Assets From (a) and (b) above) Offset by Gross Deferred Tax Liabilities Deferred Tax Assets Admitted as the result of application of SSAP No. 0. Total ((a) + (b) + (c)) $ 45,46 - - //0 (4) Ordinary (5) Capital (6) (Col 4+5) Total Admission Calculation Components SSAP No. 0 - (a) Federal Income Taxes Paid In Prior Years Recoverable Through Loss Carrybacks $ - (b) Adjusted Gross Deferred Tax Assets Expected To Be Realized (Excluding The Amount Of Deferred Tax Assets From (a) above) After Application of the Threshold Limitation. (The Lesser of (b) and (b) Below) - - Adjusted Gross Deferred Tax Assets Expected to be Realized Following the Balance Sheet Date - - Adjusted Gross Deferred Tax Assets Allowed per Limitation Threshold (c) (d) Adjusted Gross Deferred Tax Assets (Excluding The Amount Of Deferred Tax Assets From (a) and (b) above) Offset by Gross Deferred Tax Liabilities Deferred Tax Assets Admitted as the result of application of SSAP No. 0. Total ((a) + (b) + (c)) $ - - - Change (7) Ordinary (8) Capital (9) (Col 7+8) Total Admission Calculation Components SSAP No. 0 - (a) Federal Income Taxes Paid In Prior Years Recoverable Through Loss Carrybacks $ - (b) Adjusted Gross Deferred Tax Assets Expected To Be Realized (Excluding The Amount Of Deferred Tax Assets From (a) above) After Application of the Threshold Limitation. (The Lesser of (b) and (b) Below) 45,46 - Adjusted Gross Deferred Tax Assets Expected to be Realized Following the Balance Sheet Date 45,46 - Adjusted Gross Deferred Tax Assets Allowed per Limitation Threshold (c) (d) Adjusted Gross Deferred Tax Assets (Excluding The Amount Of Deferred Tax Assets From (a) and (b) above) Offset by Gross Deferred Tax Liabilities Deferred Tax Assets Admitted as the result of application of SSAP No. 0. Total ((a) + (b) + (c)) $ 45,46 - - 5.
NOTES TO FINANCIAL STATEMENTS 4 //0 () Ordinary Percent () Capital Percent () (Col +) Total Percent Impact of Tax Planning Strategies Adjusted Gross DTAs (% of Total Adjusted (a) Gross DTAs) $ - - - (b) Net Admitted Adjusted Gross DTAs (% of Total Net Admitted Adjusted Gross DTAs) - - - (4) Ordinary Percent //0 (5) Capital Percent (6) (Col 4+5) Total Percent (a) (b) Adjusted Gross DTAs (% of Total Adjusted Gross DTAs) $ - - - Net Admitted Adjusted Gross DTAs (% of Total Net Admitted Adjusted Gross DTAs) - - - (7) (Col -4) Ordinary Percent Change (8) (Col -5) Capital Percent (9) (Col 7+8) Total Percent (a) (b) (c) Adjusted Gross DTAs (% of Total Adjusted Gross DTAs) $ - - - Net Admitted Adjusted Gross DTAs (% of Total Net Admitted Adjusted Gross DTAs) - - - Does the company's tax-planning strategies include the use of reinsurance? Yes No X Current income taxes incurred consist of the following major components: 5.4
NOTES TO FINANCIAL STATEMENTS Current Income Tax: () //0 () ///0 () (Col -) Change (a) Federal $ 5,84-5,84 (b) Foreign - - - (c) Subtotal 5,84-5,84 (d) Federal income tax on net capital gains - - - (e) Utilization of capital loss carry-forwards - - - (f) Other - - - (g) Federal and foreign income taxes incurred $ 5,84-5,84 Deferred Tax Assets: (a) Ordinary: () Discounting of unpaid losses $ - - - () Unearned premium reserve - - - () Policyholder reserves - - - (4) Investments - - - (5) Deferred acquisition costs - - - (6) Policyholder dividends accrual - - - (7) Fixed Assets 7,96-7,96 (8) Compensation and benefits accrual - - - (9) Pension accrual - - - (0) Receivables - nonadmitted - - - () Net operating loss carry-forward,7,540 -,7,540 () Tax credit carry-forward - - - () Other (including items <5% of total ordinary tax assets) 45,46-45,46 Subtotal,455,99 -,455,99 (b) Statutory valuation allowance adjustment,7,540 -,7,540 (c) Nonadmitted 7,96-7,96 (d) Admitted ordinary deferred tax assets (a99 - b - c) 45,46-45,46 (e) Capital: () Investments - - - () Net capital loss carry-forward - - - () Real estate - - - (4) Other (including items <5% of total capital tax assets) - - - Subtotal - - - (f) Statutory valuation allowance adjustment - - - (g) Nonadmitted - - - (h) Admitted capital deferred tax assets (e99 - f - g) - - - (i) Admitted deferred tax assets (d + h) 45,46-45,46 Deferred Tax Liabilities (a) Ordinary: () Investments - - - () Fixed assets - - - () Deferred and uncollected premium - - - (4) Policyholder reserves - - - (5) Other (including items <5% of total ordinary tax assets) - - - (b) Subtotal - - - Capital: () Investments - - - () Real estate - - - () Other (including items <5% of total capital tax liabilities) - - - Subtotal - - - (c) Deferred tax liabilities(a99 + b99) - - - 4 Net deferred tax assets/liabilities(i - c) $ 45,46 45,46 45,46 0. Information Concerning Parent, Subsidiaries and Affiliates The Company is a 50% owned subsidiary of AmeriHealth Mercy Health Plan (AMHP) in a joint venture with Diversified Health Services, Inc., a wholly owned subsidiary of Blue Cross and Blue Shield of Florida, Inc. (BCBSFL). BCBSFL is a Florida mutual benefit nonprofit health care. AMHP is a Pennsylvania partnership formed to develop and operate managed care business for Medicaid enrollees. Amounts due to AMHP were $8,49,05 as of December, 0 and are related to start-up costs incurred for the Medicaid program which commenced business on January, 0. The Company received capital contributions in the amount of $7,97,500 each from AMHP and BCBSFL during the year ended December, 0.. Debt. Retirement Plans, Deferred Compensation, Postemployment Benefits and Compensated Absences and Other Postretirement Benefit Plans 5.5
NOTES TO FINANCIAL STATEMENTS. Capital and Surplus, Shareholders Dividend Restrictions and Quasi-Reorganizations Under applicable Florida state laws and regulations, the Company is required to maintain at all times minimum surplus equal to the greater of: (a) $,500,000; (b) ten percent of total liabilities; or (c) two percent of annualized premium. The Company is required by the State of Florida to maintain a minimum regulatory deposit of $00,000. The Company is in compliance with these requirements as of December, 0. The Company is required to maintain an insolvency protection deposit with the State of Florida equal to percent of annualized premiums. The Company is in compliance with this requirement as of December, 0. The initial deposit of $00,000 at December, 0 is reported as an aggregate write-in for invested assets on the statutory statement of admitted assets. 4. Contingencies A. Contingent Commitments In the ordinary course of business, the Company is involved in and is subject to claims, contractual disputes with providers, and other uncertainties. In the opinion of management, the ultimate disposition of these matters will not have a material effect on the Company s financial condition or results of operations. The Company is covered under the managed care errors and omissions policy maintained by AMHP for certain claims with an aggregate limit of $40,000,000 as stated in the agreements. Professional liability coverage is on a claims made basis and must be renewed or replaced with equivalent insurance if such claims incurred during its term but asserted after its expiration are to be insured. B. C. D. E Assessments Gain Contingencies Claims Related Extra Contractual Obligation and Bad Faith Losses Stemming from Lawsuits All Other Contingencies 5. Leases 6. Information About Financial Instruments With Off-Balance Sheet Risk And Financial Instruments With Concentrations of Credit Risk 7. Sale, Transfer and Servicing of Financial Assets and Extinguishments of Liabilities 8. Gain or Loss to the Reporting Entity from Uninsured A&H Plans and the Uninsured Portion of Partially Insured Plans 9. Direct Premium Written/Produced by Managing General Agents/Third Party Administrators 0. Fair Value Measurements SSAP No. 00 establishes a fair value hierarchy to increase consistency and comparability in fair value measurements and disclosures. The hierarchy is based on the inputs used in valuation and gives the highest priority to unadjusted quoted prices in active markets. The highest possible level should be used to measure fair value. The fair value hierarchy is comprised of three priority levels, which are as follows: Level Unadjusted quoted market prices for identical assets or liabilities in active markets. Level Other observable inputs, either directly or indirectly, including: Quoted prices for similar assets/liabilities in active markets; Quoted prices for identical or similar assets in non-active markets; Inputs other than quoted prices that are observable for the asset/liability; and Inputs that are derived principally from or corroborated by other observable market data. 5.6
NOTES TO FINANCIAL STATEMENTS Level Unobservable inputs that cannot be corroborated by observable market data. The fair value of cash and cash equivalents approximates their carrying value at December, 0 due to the short maturity of such instruments.. Other Items A. Extraordinary Items B. Troubled Debt Restructuring: Debtors C. Other Disclosures Pursuant to the terms of the membership interest purchase agreement with Prestige, the Company advanced Prestige $,000,000 on December, 0 in return for a subordinated surplus promissory note. Written approval by the Florida Agency for Health Care Administration is required prior to the payment of interest or principal. Interest shall accrue on the unpaid principal balance at an annual rate of 8%. The outstanding principal balance was $,000,000 at December, 0. D. Uncollectible Balances E. Business Interruption Insurance Recoveries F. State Transferable Tax Credits G. Reporting entity should disclose the aggregate amount of deposits admitted under Section 660 of the Internal Revenue Service Code. H. Hybrid Securities I. Subprime Mortgage Related Risk Exposure. Events Subsequent Management has evaluated events and transactions occurring subsequent to year end through February 8, 0, the date that the 0 annual statement was filed with the NAIC, for potential recognition and disclosure. No events or transactions occurring subsequent to year end date meet the definition of a recognized or nonrecognized subsequent event under the scope of SSAP No. 9, Subsequent Events, and therefore, do not require recognition or disclosure in the annual statement.. Reinsurance 4. Retrospectively Rated Contracts and Contracts Subject to Redetermination 5. Change in Incurred Claims and Claim Adjustment Expenses 6. Intercompany Pooling Arrangements 7. Structured Settlements 8. Health Care Receivables A. Pharmaceutical Rebate Receivables B. Risk Sharing Receivables 9. Participating Policies 0. Premium Deficiency Reserve. Anticipated Salvage and Subrogation 5.7
NOTES TO FINANCIAL STATEMENTS 5.8
GENERAL INTERROGATORIES PART - COMMON INTERROGATORIES GENERAL. Is the reporting entity a member of an Insurance Holding Company System consisting of two or more affiliated persons, one or more of which is an insurer? Yes [ X ] No [ ]. If yes, did the reporting entity register and file with its domiciliary State Insurance Commissioner, Director or Superintendent or with such regulatory official of the state of domicile of the principal insurer in the Holding Company System, a registration statement providing disclosure substantially similar to the standards adopted by the National Association of Insurance Commissioners (NAIC) in its Model Insurance Holding Company System Regulatory Act and model regulations pertaining thereto, or is the reporting entity subject to standards and disclosure requirements substantially similar to those required by such Act and regulations? Yes [ X ] No [ ] N/A [ ]. State Regulating? Florida. Has any change been made during the year of this statement in the charter, by-laws, articles of in, or deed of settlement of the reporting entity? Yes [ ] No [ X ]. If yes, date of change:. State as of what date the latest financial examination of the reporting entity was made or is being made.. State the as of date that the latest financial examination report became available from either the state of domicile or the reporting entity. This date should be the date of the examined balance sheet and not the date the report was completed or released.. State as of what date the latest financial examination report became available to other states or the public from either the state of domicile or the reporting entity. This is the release date or completion date of the examination report and not the date of the examination (balance sheet date)..4 By what department or departments?.5 Have all financial statement adjustments within the latest financial examination report been accounted for in a subsequent financial statement filed with Departments? Yes [ ] No [ ] N/A [ X ].6 Have all of the recommendations within the latest financial examination report been complied with? Yes [ ] No [ ] N/A [ X ] 4. During the period covered by this statement, did any agent, broker, sales representative, non-affiliated sales/service organization or any combination thereof under common control (other than salaried employees of the reporting entity) receive credit or commissions for or control a substantial part (more than 0 percent of any major line of business measured on direct premiums) of: 4. sales of new business? Yes [ ] No [ X ] 4. renewals? Yes [ ] No [ X ] 4. During the period covered by this statement, did any sales/service organization owned in whole or in part by the reporting entity or an affiliate, receive credit or commissions for or control a substantial part (more than 0 percent of any major line of business measured on direct premiums) of: 4. sales of new business? Yes [ ] No [ X ] 4. renewals? Yes [ ] No [ X ] 5. Has the reporting entity been a party to a merger or consolidation during the period covered by this statement? Yes [ ] No [ X ] 5. If yes, provide the name of the entity, NAIC company code, and state of domicile (use two letter state abbreviation) for any entity that has ceased to exist as a result of the merger or consolidation. Name of Entity NAIC Company Code State of Domicile 6. Has the reporting entity had any Certificates of Authority, licenses or registrations (including corporate registration, if applicable) suspended or revoked by any governmental entity during the reporting period? Yes [ ] No [ X ] 6. If yes, give full information 7. Does any foreign (non-united States) person or entity directly or indirectly control 0% or more of the reporting entity? Yes [ ] No [ X ] 7. If yes, 7. State the percentage of foreign control 7. State the nationality(s) of the foreign person(s) or entity(s); or if the entity is a mutual or reciprocal, the nationality of its manager or attorney-in-fact and identify the type of entity(s) (e.g., individual,, government, manager or attorneyin-fact). Nationality Type of Entity 6