ASSETS Assets Current Statement Date 4 Nonadmitted Assets Net Admitted Assets (Cols. - ) December Prior Year Net Admitted Assets. Bonds 40,044,057 40,044,057 59,986,649. Stocks:. Preferred stocks 0 0. Common stocks 6,00,66 6,00,66 8,446,99. Mortgage loans on real estate:. First liens 4,60,84 4,60,84 4,00,000. Other than first liens 0 0 4. Real estate: 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) 4,000 4,000 0 0 5. Cash ($ 8,789,00 ), cash equivalents ($ 46,09 ) and short-term investments ($,8,684 ),075,9,075,9 5,877,94 6. Contract loans (including $ premium notes) 0 0 7. Derivatives 0 0 0 8. Other invested assets 45,90,78 45,90,78 0,796,409 9. Receivables for securities,455,740,455,740 0 0. Securities lending reinvested collateral assets 0 0. Aggregate write-ins for invested assets 0 0 0 0. Subtotals, cash and invested assets (Lines to ) 0,7,078 4,000 0,697,078 09,406,75. Title plants less $ charged off (for Title insurers only) 0 0 4. Investment income due and accrued 89,990 89,990 576,060 5. Premiums and considerations: 5. Uncollected premiums and agents balances in the course of collection,47,5,00,588,44,565 99,69 5. Deferred premiums, agents balances and installments booked but deferred and not yet due (including $ earned but unbilled premiums) 5,9,0 5,9,0 7,5,40 5. Accrued retrospective premiums ($ ) and contracts subject to redetermination ($ ) 0 0 6. Reinsurance: 6. Amounts recoverable from reinsurers 6,5,04 6,5,04 6,56,9 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 7,94,85 7,94,85 7,657,0 8. Net deferred tax asset 9,699,960,5,6 6,74,64,70, 9. Guaranty funds receivable or on deposit 9 9 90 0. Electronic data processing equipment and software 669,98 669,98 0 0. Furniture and equipment, including health care delivery assets ($ ) 0 0. Net adjustment in assets and liabilities due to foreign exchange rates 0 0. Receivables from parent, subsidiaries and affiliates 6,069,8 4,55,46,544,6,554,0 4. Health care ($ ) and other amounts receivable 0 0 5. Aggregate write-ins for other-than-invested assets 605,89 55,687 49,60 9,465,794 6. Total assets excluding Separate Accounts, Segregated Accounts and Protected Cell Accounts (Lines to 5) 9,06,9 9,9,980 09,48,59 87,68,054 7. From Separate Accounts, Segregated Accounts and Protected Cell Accounts 0 0 8. Total (Lines 6 and 7) 9,06,9 9,9,980 09,48,59 87,68,054 0. 0. 0. DETAILS OF WRITE-INS 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. Other receivables - deductibles 76,47 6,47 50,000 50,000 50. State income tax receivable 59,5 59,5 56,4 50. Receivable from pools 40,487 40,487 6,046 598. Summary of remaining write-ins for Line 5 from overflow page 9,50 9,50 0 9,5,606 599. Totals (Lines 50 through 50 plus 598) (Line 5 above) 605,89 55,687 49,60 9,465,794
LIABILITIES, SURPLUS AND OTHER FUNDS Current Statement Date December, Prior Year. Losses (current accident year $ 8,08,508 ) 6,875,74 47,406,5. Reinsurance payable on paid losses and loss adjustment expenses,98,8,059,47. Loss adjustment expenses 7,750,656 7,66,76 4. Commissions payable, contingent commissions and other similar charges (69,7),7,540 5. Other expenses (excluding taxes, licenses and fees) 657,95 678,56 6. Taxes, licenses and fees (excluding federal and foreign income taxes),,0 976,099 7.Current federal and foreign income taxes (including $ on realized capital gains (losses)) 0 7. Net deferred tax liability 0 8. Borrowed money $ and interest thereon $ 0 9. Unearned premiums (after deducting unearned premiums for ceded reinsurance of $ 57,8,7 and including warranty reserves of $ and accrued accident and health experience rating refunds including $ for medical loss ratio rebate per the Public Health Service Act) 48,97,04 47,65,974 0. Advance premium 0. Dividends declared and unpaid:. Stockholders 0. Policyholders 0. Ceded reinsurance premiums payable (net of ceding commissions),958,60 7,04,50. Funds held by company under reinsurance treaties 0 4. Amounts withheld or retained by company for account of others 9,8 6,869 5. Remittances and items not allocated (7,85) 6,85 6. Provision for reinsurance (including $ certified) 0 7. Net adjustments in assets and liabilities due to foreign exchange rates 0 8. Drafts outstanding 0 9. Payable to parent, subsidiaries and affiliates 5,964 0. Derivatives 0 0. Payable for securities,697,040 0. Payable for securities lending 0. Liability for amounts held under uninsured plans 0 4. Capital notes $ and interest thereon $ 0 5. Aggregate write-ins for liabilities,857,9 66,866 6. Total liabilities excluding protected cell liabilities (Lines through 5) 59,968,86 57,64,606 7. Protected cell liabilities 0 8. Total liabilities (Lines 6 and 7) 59,968,86 57,64,606 9. Aggregate write-ins for special surplus funds 0 0 0. Common capital stock,000,004,000,004. Preferred capital stock 0 0. Aggregate write-ins for other than special surplus funds 0 0. Surplus notes 7,900,000 7,900,000 4. Gross paid in and contributed surplus,7,075,7,075 5. Unassigned funds (surplus) 5,5,44 (4,0,6) 6. Less treasury stock, at cost: 6. shares common (value included in Line 0 $ ) 0 6. shares preferred (value included in Line $ ) 0 7. Surplus as regards policyholders (Lines 9 to 5, less 6) 49,79, 9,74,448 8. Totals (Page, Line 8, Col. ) 09,48,59 87,68,054 DETAILS OF WRITE-INS 50. Unearned ceding commission,68,49 48,900 50. Escheatables 09,06 09,988 50. Miscellaneous payable 5,60,4 598. Summary of remaining write-ins for Line 5 from overflow page (50,486) (44,56) 599. Totals (Lines 50 through 50 plus 598) (Line 5 above),857,9 66,866 90. 0 90. 0 90. 998. Summary of remaining write-ins for Line 9 from overflow page 0 0 999. Totals (Lines 90 through 90 plus 998) (Line 9 above) 0 0 0. 0. 0. 98. Summary of remaining write-ins for Line from overflow page 0 0 99. Totals (Lines 0 through 0 plus 98) (Line above) 0 0
STATEMENT OF INCOME Current Year to Date Prior Year to Date Prior Year Ended December UNDERWRITING INCOME. Premiums earned:. Direct (written $ 7,8,8 ) 7,964,85 7,47,007 50,9,08. Assumed (written $ 9,4,996 ) 08,466,68 98,768,808 5,56,5. Ceded (written $ 86,764, ) 78,050,87 7,58,570 97,08,84.4 Net (written $ 69,94,595 ) 68,80,66 64,70,45 88,456,969 DEDUCTIONS:. Losses incurred (current accident year $ 8,549,887 ):. Direct 4,6,0,46,464,679,978. Assumed 44,84,9 8,955,67 95,005,0. Ceded 0,9,5 6,67,44 65,76,88.4 Net 8,8,7 5,745,667 6,959,00. Loss adjustment expenses incurred,9,554,669,8,0,6 4. Other underwriting expenses incurred 7,74,06 7,9,8,8,95 5. Aggregate write-ins for underwriting deductions 4,969 4,75 4,97 6. Total underwriting deductions (Lines through 5) 58,48,676 55,84,05 07,40,649 7. Net income of protected cells 0 0 8. Net underwriting gain (loss) (Line minus Line 6 + Line 7) 0,0,690 8,859,94 (8,78,679) INVESTMENT INCOME 9. Net investment income earned 800,458 858,65,065,576 0. Net realized capital gains (losses) less capital gains tax of $ 4,060 409,8 54,469 55,95. Net investment gain (loss) (Lines 9 + 0),0,79,400,,60,5 OTHER INCOME. Net gain or (loss) from agents' or premium balances charged off (amount recovered $,5 amount charged off $ 00,9 ) (98,769) (57,04) (646,60). Finance and service charges not included in premiums 45,48 58,08,85 4. Aggregate write-ins for miscellaneous income (7,06) (4,7) (65,50) 5. Total other income (Lines through 4) (80,87) (7,48) (800,87) 6. Net income before dividends to policyholders, after capital gains tax and before all other federal and foreign income taxes (Lines 8 + + 5),6,4 9,886,067 (7,98,455) 7. Dividends to policyholders 0 0 8. Net income, after dividends to policyholders, after capital gains tax and before all other federal and foreign income taxes (Line 6 minus Line 7),6,4 9,886,067 (7,98,455) 9. Federal and foreign income taxes incurred (40,04),580,645 (,86,69) 0. Net income (Line 8 minus Line 9)(to Line ),56,84 7,05,4 (5,55,76) CAPITAL AND SURPLUS ACCOUNT. Surplus as regards policyholders, December prior year 9,74,448 50,476,049 50,476,049. Net income (from Line 0),56,84 7,05,4 (5,55,76). Net transfers (to) from Protected Cell accounts 0 0 4. Change in net unrealized capital gains or (losses) less capital gains tax of $ 89,59 8,,45,785 895,97 5. Change in net unrealized foreign exchange capital gain (loss) 0 0 6. Change in net deferred income tax (,9,90) (,90,56) (97,6) 7. Change in nonadmitted assets 4,6,58 4,80,607 (4,79,4) 8. Change in provision for reinsurance 0 0 9. Change in surplus notes 0 0 0. Surplus (contributed to) withdrawn from protected cells 0 0. Cumulative effect of changes in accounting principles 0 0. Capital changes:. Paid in 0 0. Transferred from surplus (Stock Dividend) 0 0. Transferred to surplus 0 0. Surplus adjustments:. Paid in 0 9,5,606. Transferred to capital (Stock Dividend) 0 0. Transferred from capital 0 0 4. Net remittances from or (to) Home Office 0 0 5. Dividends to stockholders (,500,000) 0 0 6. Change in treasury stock 0 0 7. Aggregate write-ins for gains and losses in surplus 0 (6,66) (6,66) 8. Change in surplus as regards policyholders (Lines through 7) 9,454,875 0,,64 (0,75,60) 9. Surplus as regards policyholders, as of statement date (Lines plus 8) 49,79, 60,688,69 9,74,448 DETAILS OF WRITE-INS 050. CLAD Fees 9,46 (6,74) (6,74) 050. Premium deficiency expense 4,7 4,465 49,0 050. 0 0 0598. Summary of remaining write-ins for Line 5 from overflow page 0 0 0 0599. TOTALS (Lines 050 through 050 plus 0598) (Line 5 above) 4,969 4,75 4,97 40. Retroactive reinsurance income/(expense) 4,95,5 (9,840) 40. Miscellaneous income (,4) 9 (8,04) 40. Fines & Penalties (0,77) (6,75) (7,76) 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) (7,06) (4,7) (65,50) 70. Change in deferred gain on real estate (6,66) (6,66) 70. 0 0 70. 798. Summary of remaining write-ins for Line 7 from overflow page 0 0 0 799. TOTALS (Lines 70 through 70 plus 798) (Line 7 above) 0 (6,66) (6,66) 4
CASH FLOW Current Year To Date Prior Year To Date Prior Year Ended December Cash from Operations. Premiums collected net of reinsurance 59,50,46 7,64,055 9,695,0. Net investment income,74,85,7,48,480,9. Miscellaneous income (80,84) (7,48) (800,87) 4. Total (Lines to ) 60,74,45 74,44,87 9,75,6 5. Benefit and loss related payments 47,990,958,560,7 4,97,50 6. Net transfers to Separate Accounts, Segregated Accounts and Protected Cell Accounts 0 0 0 7. Commissions, expenses paid and aggregate write-ins for deductions,6,88 8,0,46 6,95,9 8. Dividends paid to policyholders 0 0 0 9. Federal and foreign income taxes paid (recovered) net of $ tax on capital gains (losses) 0 0 500,000 0. Total (Lines 5 through 9) 69,64,84 60,66,47 79,09,79. Net cash from operations (Line 4 minus Line 0) (8,900,89),778,870,8,469 Cash from Investments. Proceeds from investments sold, matured or repaid:. Bonds 6,095,57 8,975,9 9,0,88. Stocks 5,7,5 5,597,65 6,6,06. Mortgage loans 9,66 0 0.4 Real estate 0 0 0.5 Other invested assets,60,5,,45 4,809,54.6 Net gains or (losses) on cash, cash equivalents and short-term investments 0 0 0.7 Miscellaneous proceeds,4,00 0 0.8 Total investment proceeds (Lines. to.7) 6,45,5 6,706,6 0,004,99. Cost of investments acquired (long-term only):. Bonds 6,605,800,844,046 4,59,689. Stocks,50,000 4,850,000 7,900,000. Mortgage loans 0 0 0.4 Real estate 0 0 0.5 Other invested assets 0,080,000 56,097 56,097.6 Miscellaneous applications 0 0 0.7 Total investments acquired (Lines. to.6) 9,05,800 9,56,4,05,786 4. Net increase (or decrease) in contract loans and premium notes 0 0 0 5. Net cash from investments (Line.8 minus Line.7 and Line 4) 7,47,45 (,549,5) 6,950,4 Cash from Financing and Miscellaneous Sources 6. Cash provided (applied): 6. Surplus notes, capital notes 0 0 0 6. Capital and paid in surplus, less treasury stock 0 0 9,5,606 6. Borrowed funds 0 0 0 6.4 Net deposits on deposit-type contracts and other insurance liabilities 0 0 6.5 Dividends to stockholders,500,000 0 0 6.6 Other cash provided (applied),8,554 (,56,658) (,989,9) 7. Net cash from financing and miscellaneous sources (Line 6. through Line 6.4 minus Line 6.5 plus Line 6.6) (,8,446) (,56,658) (,75,7) 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) 7,98,67 8,667,689 7,497,50 9. Cash, cash equivalents and short-term investments: 9. Beginning of year 5,877,96 8,80,47 8,80,47 9. End of period (Line 8 plus Line 9.),075,9 7,047,86 5,877,96 5
GENERAL INTERROGATORIES PART - COMMON INTERROGATORIES GENERAL. Did the reporting entity experience any material transactions requiring the filing of Disclosure of Material Transactions with the State of Domicile, as required by the Model Act? Yes [ ] No [X]. If yes, has the report been filed with the domiciliary state? Yes [ ] No [ ]. Has any change been made during the year of this statement in the charter, by-laws, articles of incorporation, or deed of settlement of the reporting entity? Yes [ ] No [X]. If yes, date of change:. 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, complete Schedule Y, Parts and A.. Have there been any substantial changes in the organizational chart since the prior quarter end? Yes [X] No [ ]. If the response to. is yes, provide a brief description of those changes. opton Insurance Agency Inc. was formed. The new entity is a wholly owned subsidiary of UBI Holdings Inc..4 Is the reporting entity publicly traded or a member of a publicly traded group? Yes [X] No [ ].5 If the response to.4 is yes, provide the CIK (Central Index Key) code issued by the SEC for the entity/group. 00059894 4. Has the reporting entity been a party to a merger or consolidation during the period covered by this statement? Yes [ ] No [X] 4. If yes, provide the name of 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 5. If the reporting entity is subject to a management agreement, including third-party administrator(s), managing general agent(s), attorney-infact, or similar agreement, have there been any significant changes regarding the terms of the agreement or principals involved? Yes [ ] No [X] NA [ ] If yes, attach an explanation. 6. State as of what date the latest financial examination of the reporting entity was made or is being made. //05 6. 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. //05 6. 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). 04/5/07 6.4 By what department or departments? Illinois Department of Insurance 6.5 Have all financial statement adjustments within the latest financial examination report been accounted for in a subsequent financial statement filed with Departments? Yes [ ] No [ ] NA [X] 6.6 Have all of the recommendations within the latest financial examination report been complied with? Yes [X] No [ ] NA [ ] 7. Has this 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? 7. If yes, give full information: Yes [ ] No [X] 8. Is the company a subsidiary of a bank holding company regulated by the Federal Reserve Board? Yes [ ] No [X] 8. If response to 8. is yes, please identify the name of the bank holding company. 8. Is the company affiliated with one or more banks, thrifts or securities firms? Yes [ ] No [X] 8.4 If response to 8. is yes, please provide below the names and location (city and state of the main office) of any affiliates regulated by a federal regulatory services agency [i.e. the Federal Reserve Board (FRB), the Office of the Comptroller of the Currency (OCC), the Federal Deposit Insurance Corporation (FDIC) and the Securities Exchange Commission (SEC)] and identify the affiliate s primary federal regulator.] Affiliate Name Location (City, State) FRB 4 OCC 5 FDIC 6 SEC 7
GENERAL INTERROGATORIES 9. Are the senior officers (principal executive officer, principal financial officer, principal accounting officer or controller, or persons performing similar functions) of the reporting entity subject to a code of ethics, which includes the following standards? Yes [X] No [ ] (a) Honest and ethical conduct, including the ethical handling of actual or apparent conflicts of interest between personal and professional relationships; (b) Full, fair, accurate, timely and understandable disclosure in the periodic reports required to be filed by the reporting entity; (c) Compliance with applicable governmental laws, rules and regulations; (d) The prompt internal reporting of violations to an appropriate person or persons identified in the code; and (e) Accountability for adherence to the code. 9. If the response to 9. is No, please explain: 9. Has the code of ethics for senior managers been amended? Yes [ ] No [X] 9. If the response to 9. is Yes, provide information related to amendment(s). 9. Have any provisions of the code of ethics been waived for any of the specified officers? Yes [ ] No [X] 9. If the response to 9. is Yes, provide the nature of any waiver(s). FINANCIAL 0. Does the reporting entity report any amounts due from parent, subsidiaries or affiliates on Page of this statement? Yes [X] No [ ] 0. If yes, indicate any amounts receivable from parent included in the Page amount: $ 4,9,456 INVESTMENT. Were any of the stocks, bonds, or other assets of the reporting entity loaned, placed under option agreement, or otherwise made available for use by another person? (Exclude securities under securities lending agreements.). If yes, give full and complete information relating thereto: Yes [ ] No [X]. Amount of real estate and mortgages held in other invested assets in Schedule BA: $ 5,5,56. Amount of real estate and mortgages held in short-term investments: $ 4. Does the reporting entity have any investments in parent, subsidiaries and affiliates? Yes [X] No [ ] 4. If yes, please complete the following: Prior Year-End Book/Adjusted Carrying Value Current Quarter Book/Adjusted Carrying Value 4. Bonds $ $ 4. Preferred Stock $ $ 4. Common Stock $ $ 4.4 Short-Term Investments $ $ 4.5 Mortgage Loans on Real Estate $ 4,00,000 $ 4,60,84 4.6 All Other $ $ 6,08,9 4.7 Total Investment in Parent, Subsidiaries and Affiliates (Subtotal Lines 4. to 4.6) $ 4,00,000 $ 0,98,6 4.8 Total Investment in Parent included in Lines 4. to 4.6 above $ $ 5. Has the reporting entity entered into any hedging transactions reported on Schedule DB? Yes [ ] No [X] 5. If yes, has a comprehensive description of the hedging program been made available to the domiciliary state? Yes [ ] No [ ] If no, attach a description with this statement. 7.
GENERAL INTERROGATORIES 6 For the reporting entity s security lending program, state the amount of the following as of the current statement date: 6. Total fair value of reinvested collateral assets reported on Schedule DL, Parts and $ 0 6. Total book adjusted/carrying value of reinvested collateral assets reported on Schedule DL, Parts and $ 0 6. Total payable for securities lending reported on the liability page $ 0 7. Excluding items in Schedule E Part Special Deposits, real estate, mortgage loans and investments held physically in the reporting entity s offices, vaults or safety deposit boxes, were all stocks, bonds and other securities, owned throughout the current year held pursuant to a custodial agreement with a qualified bank or trust company in accordance with Section, III General Examination Considerations, F. Outsourcing of Critical Functions, Custodial or Safekeeping Agreements of the NAIC Financial Condition Examiners Handbook? Yes [X] No [ ] 7. For all agreements that comply with the requirements of the NAIC Financial Condition Examiners Handbook, complete the following: Name of Custodian(s) Asset Allocation & Management Company, LLC Custodian Address 500 Kingsley Drive, Maildrop M0BJ, Cincinnati, OH 457 7. For all agreements that do not comply with the requirements of the NAIC Financial Condition Examiners Handbook, provide the name, location and a complete explanation: Name(s) Location(s) Complete Explanation(s) 7. Have there been any changes, including name changes, in the custodian(s) identified in 7. during the current quarter? Yes [ ] No [X] 7.4 If yes, give full and complete information relating thereto: Old Custodian New Custodian Date of Change 4 Reason 7.5 Investment management Identify all investment advisors, investment managers, broker/dealers, including individuals that have the authority to make investment decisions on behalf of the reporting entity. For assets that are managed internally by employees of the reporting entity, note as such. [ that have access to the investment accounts ; handle securities ] Name of Firm or Individual Asset Allocation & Management Company, LLC U Affiliation 7.5097For those firms/individuals listed in the table for Question 7.5, do any firms/individuals unaffiliated with the reporting entity (i.e., designated with a U ) manage more than 0% of the reporting entity s assets? Yes [ X ] No [ ] 7.5098For firms/individuals unaffiliated with the reporting entity (i.e., designated with a U ) listed in the table for Question 7.5, does the total assets under management aggregate to more than 50% of the reporting entity s assets? Yes [ ] No [ X ] 7.6 For those firms or individuals listed in the table for 7.5 with an affiliation code of A (affiliated) or U (unaffiliated), provide the information for the table below. Central Registration Depository Number Name of Firm or Individual 09875 Asset Allocation & Management Legal Entity Identifier (LEI) 4 Registered With Securities And Exchange Commission DS 5 Investment Management Agreement (IMA) Filed 8. Have all the filing requirements of the Purposes and Procedures Manual of the NAIC Investment Analysis Office been followed? Yes [X] No [ ] 8. If no, list exceptions: 9. By self-designating 5*GI securities, the reporting entity is certifying the following elements for each self-designated 5*GI security: a. Documentation necessary to permit a full credit analysis of the security does not exist. b. Issuer or obligor is current on all contracted interest and principal payments. c. The insurer has an actual expectation of ultimate payment of all contracted interest and principal. Has the reporting entity self-designated 5*GI securities? Yes [ ] No [X] 7.
GENERAL INTERROGATORIES PART - PROPERTY & CASUALTY INTERROGATORIES. If the reporting entity is a member of a pooling arrangement, did the agreement or the reporting entity's participation change? Yes [ ] No [X] NA [ ] If yes, attach an explanation.. Has the reporting entity reinsured any risk with any other reporting entity and agreed to release such entity from liability, in whole or in part, from any loss that may occur on the risk, or portion thereof, reinsured? Yes [ ] No [X] If yes, attach an explanation.. Have any of the reporting entity's primary reinsurance contracts been canceled? Yes [ ] No [X]. If yes, give full and complete information thereto. 4. Are any of the liabilities for unpaid losses and loss adjustment expenses other than certain workers' compensation tabular reserves (see Annual Statement Instructions pertaining to disclosure of discounting for definition of tabular reserves, ) discounted at a rate of interest greater than zero? Yes [ ] No [X] 4. If yes, complete the following schedule: Line of Business Maximum Interest Discount Rate 4 Unpaid Losses TOTAL DISCOUNT 5 6 Unpaid LAE IBNR 7 TOTAL DISCOUNT TAKEN DURING PERIOD 8 9 0 Unpaid Unpaid Losses LAE IBNR TOTAL TOTAL 0 0 0 0 0 0 0 0 5. Operating Percentages: 5. A&H loss percent % 5. A&H cost containment percent % 5. A&H expense percent excluding cost containment expenses % 6. Do you act as a custodian for health savings accounts? Yes [ ] No [X] 6. If yes, please provide the amount of custodial funds held as of the reporting date. $ 6. Do you act as an administrator for health savings accounts? Yes [ ] No [X] 6.4 If yes, please provide the balance of the funds administered as of the reporting date. $ 7. Is the reporting entity licensed or chartered, registered, qualified, eligible or writing business in at least two states? Yes [X] No [ ] 7. If no, does the reporting entity assume reinsurance business that covers risks residing in at least one state other than the state of domicile of the reporting entity? Yes [ ] No [ ] 8
NAIC Company Code ID Number Name of Reinsurer SCHEDULE F - CEDED REINSURANCE Showing All New Reinsurers - Current Year to Date 4 Domiciliary Jurisdiction Type of Reinsurer 5 6 Certified Reinsurer Rating ( through 6) 7 Effective Date of Certified Reinsurer Rating 9
States, etc. SCHEDULE T - EXHIBIT OF PREMIUMS WRITTEN Current Year to Date Allocated by States and Territories Direct Premiums Written Direct Losses Paid (Deducting Salvage) Direct Losses Unpaid 4 5 6 7 Active Status (a) Current Year To Date Prior Year To Date Current Year To Date Prior Year To Date Current Year To Date Prior Year To Date. Alabama AL L 49,70 86,9 4,07,897 9,9 (4,444). Alaska AK L 0 0 0. Arizona AZ L,78 56,9 54,5,404,550 70,09 (,00,60) 4. Arkansas AR L 84, 60,45 46,48 88,99 0,5 (68,00) 5. California CA N 0 0 0 6. Colorado CO L 90,50 5,0 9,7 0,980 4,4 55,60 7. Connecticut CT N 0 0 0 8. Delaware DE L 0 0 0 9. Dist. Columbia DC L 0 0 0 0. Florida FL L 0 (40) (60) 740,960. Georgia GA L,66,705,80,677,8,08,594,6,7,6 460,45. Hawaii HI L 0 0 0. Idaho ID L 47,4 7,460 6,58 79,896 4,655 (,755) 4. Illinois IL L 6,68,779 7,44,798 4,79,546,674,85,7,85,706,57 5. Indiana IN L 457,9 566,489 44,69 4,87 4,05 85,6 6. Iowa IA L 0 0 0 7. Kansas KS L 9,560,4 87,60 8,88,75 8,7 8. Kentucky KY L 0 0 0 9. Louisiana LA L,58,57,40,54,9,45 4,6,88,9,950,096,90 0. Maine ME N 0 0 0. Maryland MD L 70,869,58 85,869 0,67 48,4 4,4. Massachusetts MA L 0 0 0. Michigan MI L 59,09,668,98 59,0,004,644 96,759 5,40 4. Minnesota MN L 0 0 0 5. Mississippi MS L 778,94 4,8 65,6 459,85 54,07 (60,409) 6. Missouri MO L 45,546 465,6 5,4,77,456 6,668 (8,9) 7. Montana MT L 0 0 0 8. Nebraska NE L,4 00,085 8,680 80,5 78,670 8,986 9. Nevada NV L 0 0 0 0. New Hampshire NH N 0 0 0. New Jersey NJ L,7,67,755,807 650,5,64,7,5,,507. New Mexico NM L,96 8,750 9,4 96,8 468,846 0,49. New York NY L,505,074 49,587 46,64,90 8,78 47,47 4. No. Carolina NC L 0 0 0 5. No. Dakota ND L 0 0 0 6. Ohio OH L 4,90,6 5,79,80,98,4,46,44,86,00,678,6 7. Oklahoma OK L 0 0 0 8. Oregon OR L 86,87 54,05 88,75 68,57 6,750 (98,76) 9. Pennsylvania PA L 578,74 70,9 88,84 46,75 94,750 99,874 40. Rhode Island RI N 0 0 0 4. So. Carolina SC L 508,4 880,864,006,5 650,556 67,6,07,899 4. So. Dakota SD L 0 0 0 4. Tennessee TN L 57,05 6,5 4,4 90,577 40,686 405,679 44. Texas TX L 0 (48) () 48 5,00 45. Utah UT L 4,086 4,999 5,860,96 4,448 50,754 46. Vermont VT L 0 0 0 47. Virginia VA L 5,77, 4,907,50,04,6,90,56,88,556,507,5 48. Washington WA L,55,89 5,790,69,49,46,008,996,44,076,468,0 49. West Virginia WV L 0 0 0 50. Wisconsin WI N 0 0 0 5. Wyoming WY L 0 0 0 5. American Samoa AS N 0 0 0 5. Guam GU N 0 0 0 54. Puerto Rico PR N 0 0 0 55. U.S. Virgin Islands VI N 0 0 0 56. Northern Mariana Islands MP N 0 0 0 57. Canada CAN N 0 0 0 58. Aggregate Other Alien OT XXX 0 0 0 0 0 0 59. Totals XXX 7,8,8 40,985,9 9,77,9,08,60 8,940,76 0,67,69 DETAILS OF WRITE-INS 5800. XXX 5800. XXX 5800. XXX 58998. Summary of remaining writeins for Line 58 from overflow page XXX 0 0 0 0 0 0 58999. TOTALS (Lines 5800 through 5800 plus 58998) (Line 58 above) XXX 0 0 0 0 0 0 (a) Active Status Counts L Licensed or Chartered Licensed insurance carrier or domiciled RRG 45 R Registered Non-domiciled RRGs 0 E Eligible Reporting entities eligible or approved to write surplus lines in the state (other than their state of domicile See DSLI) 0 Q Qualified Qualified or accredited reinsurer 0 D Domestic Surplus Lines Insurer (DSLI) Reporting entities authorized to write surplus lines in the state of domicile 0 N None of the above Not allowed to write business in the state 0
SCHEDULE Y - INFORMATION CONCERNING ACTIVITIES OF INSURER MEMBERS OF A HOLDING COMPANY GROUP PART - ORGANIZATIONAL CHART
SCHEDULE Y PART A DETAIL OF INSURANCE HOLDING COMPANY SYSTEM 4 5 6 7 Name of Securities Exchange if Publicly Traded (U.S. or 8 NAIC Names of Group Code Group Name Company Code ID Number Federal RSSD CIK International) Parent, Subsidiaries or Affiliates Domiciliary Location Entity Directly Controlled by (Name of Entity/Person) Influence, Other) Percentage Ultimate Controlling Entity(ies)/Person(s) (Y/N) * 00000 00000 7-5466079 NASDAQ Atlas Financial Holdings, Inc CYM UIP Ownership 0.0 0 American Insurance Acquisition, Atlas Financial 00000 00000 7-59769 Inc DE UDP Atlas Financial Holdings, Inc Ownership 00.0 Holdings Inc 0 American Country Insurance American Service Insurance Atlas Financial 04795 Atlas Financial Holdings Group 87 6-4685 Company IL DS Company, Inc Ownership 00.0 Holdings Inc 0 American Service Insurance American Insurance Atlas Financial 04795 Atlas Financial Holdings Group 4897 6-96 Company, Inc IL Acquisition, Inc Ownership 00.0 Holdings Inc 0 American Insurance Atlas Financial 04795 Atlas Financial Holdings Group 89 4-07609 Gateway Insurance Company MO IA Acquisition, Inc Ownership 00.0 Holdings Inc 0 American Insurance Atlas Financial 00000 00000 06-65 Anchor Holdings Group, Inc NY NIA Acquisition, Inc Ownership 00.0 Holdings Inc 0 Global Liberty Insurance Atlas Financial 04795 Atlas Financial Holdings Group 09-778 Company of New York NY IA Anchor Holdings Group, Inc Ownership 00.0 Holdings Inc 0 American Insurance Atlas Financial 00000 00000 06-6895 Anchor Group Management, Inc NY NIA Acquisition, Inc Ownership 00.0 Holdings Inc 0 Plainview Premium Finance American Insurance Atlas Financial 00000 00000 0-49956 Company, Inc DE NIA Acquisition, Inc Ownership 00.0 Holdings Inc 0 American Insurance Atlas Financial 00000 00000 8-797749 UBI Holdings, Inc DE NIA Acquisition, Inc Ownership 00.0 Holdings Inc 0 Atlas Financial 00000 00000 8-94857 DriveOn Digital IP, Inc DE NIA UBI Holdings, Inc Ownership 00.0 Holdings Inc 0 9 0 Relationship to Reporting Type of Control (Ownership, Board, Management, Attorney-in-Fact, 00000 00000 8-80559 opton Insurance Agency, Inc DE NIA UBI Holdings, Inc Ownership 00.0 If Control is Ownership Provide 4 5 Is an SCA Filing Required? 6 Atlas Financial Holdings Inc 0 Asterisk Explanation
PART - LOSS EXPERIENCE Direct Premiums Earned Current Year to Date 4 Direct Losses Direct Loss Incurred Percentage Prior Year to Date Direct Loss Percentage Line of Business. Fire 0.0 0.0. Allied lines 0.0 0.0. Farmowners multiple peril 0.0 0.0 4. Homeowners multiple peril 0.0 0.0 5. Commercial multiple peril 0.0 0.0 6. Mortgage guaranty 0.0 0.0 8. Ocean marine 0.0 0.0 9. Inland marine 0.0 0.0 0. Financial guaranty 0.0 0.0. Medical professional liability -occurrence 0.0 0.0. Medical professional liability -claims made 0.0 0.0. Earthquake 0.0 0.0. Group accident and health 0.0 0.0 4. Credit accident and health 0.0 0.0 5. Other accident and health 0.0 0.0 6. Workers compensation 0.0 0.0 7. Other liability occurrence,56,54 80,050 5. 5. 7. Other liability-claims made 0.0 0.0 7. Excess Workers Compensation 0.0 0.0 8. Products liability-occurrence 0.0 0.0 8. Products liability-claims made 0.0 0.0 9.,9. Private passenger auto liability 0.0 0.0 9.,9.4 Commercial auto liability,7,58,4, 7.6.6. Auto physical damage 4,75,70,56,98 5.7 55.4. Aircraft (all perils) 0.0 0.0. Fidelity 0.0 0.0 4. Surety 4 4.9 48.5 6. Burglary and theft 0.0 0.0 7. Boiler and machinery 0.0 0.0 8. Credit 0.0 0.0 9. International 0.0 0.0 0. Warranty 0.0 0.0. Reinsurance - Nonproportional Assumed Property XXX XXX XXX XXX. Reinsurance - Nonproportional Assumed Liability XXX XXX XXX XXX. Reinsurance - Nonproportional Assumed Financial Lines XXX XXX XXX XXX 4. Aggregate write-ins for other lines of business 0 0 0.0 0.0 5. TOTALS 7,964,85 4,6,0 7.8 5.9 DETAILS OF WRITE-INS 40. 0.0 0.0 40. 0.0 0.0 40. 0.0 0.0 498. Sum. of remaining write-ins for Line 4 from overflow page 0 0 0.0 0.0 499. Totals (Lines 40 through 40 plus 498) (Line 4) 0 0 0.0 0.0 PART - DIRECT PREMIUMS WRITTEN Current Quarter Current Year to Date Prior Year Year to Date Line of Business. Fire 0 0. Allied lines 0 0. Farmowners multiple peril 0 0 4. Homeowners multiple peril 0 0 5. Commercial multiple peril 0 0 6. Mortgage guaranty 0 0 8. Ocean marine 0 0 9. Inland marine 0 0 0. Financial guaranty 0 0. Medical professional liability-occurrence 0 0. Medical professional liability-claims made 0 0. Earthquake 0 0. Group accident and health 0 0 4. Credit accident and health 0 0 5. Other accident and health 0 0 6. Workers compensation 0 0 7. Other liability occurrence 509,40,650,004,494,89 7. Other liability-claims made 0 0 7. Excess Workers Compensation 0 0 8. Products liability-occurrence 0 0 8. Products liability-claims made 0 0 9.,9. Private passenger auto liability 0 0 9.,9.4 Commercial auto liability 7,504,086,480,564 4,796,9. Auto physical damage 94,07 4,5,00 4,69,84. Aircraft (all perils) 0 0. Fidelity 0 0 4. Surety 6 4 97 6. Burglary and theft 0 0 7. Boiler and machinery 0 0 8. Credit 0 0 9. International 0 0 0. Warranty 0 0. Reinsurance - Nonproportional Assumed Property XXX XXX XXX. Reinsurance - Nonproportional Assumed Liability XXX XXX XXX. Reinsurance - Nonproportional Assumed Financial Lines XXX XXX XXX 4. Aggregate write-ins for other lines of business 0 0 0 5. TOTALS 8,97,679 7,8,8 40,985,9 DETAILS OF WRITE-INS 40. 0 0 40. 0 0 40. 0 0 498. Sum. of remaining write-ins for Line 4 from overflow page 0 0 0 499. Totals (Lines 40 through 40 plus 498) (Line 4) 0 0 0
PART (000 omitted) LOSS AND LOSS ADJUSTMENT EXPENSE RESERVES SCHEDULE 4 5 6 7 8 9 0 Years in Which Losses Occurred Prior Year-End Known Case Loss and LAE Reserves Prior Year-End IBNR Loss and LAE Reserves Total Prior Year-End Loss and LAE Reserves (Cols. + ) 08 Loss and LAE Payments on Claims Reported as of Prior Year-End 08 Loss and LAE Payments on Claims Unreported as of Prior Year-End Total 08 Loss and LAE Payments (Cols. 4 + 5) Q.S. Date Known Case Loss and LAE Reserves on Claims Reported and Open as of Prior Year End Q.S. Date Known Case Loss and LAE Reserves on Claims Reported or Reopened Subsequent to Prior Year End Q.S. Date IBNR Loss and LAE Reserves Total Q.S. Loss and LAE Reserves (Cols.7 + 8 + 9) Prior Year-End Known Case Loss and LAE Reserves Developed (Savings)/ Deficiency (Cols. 4 + 7 minus Col. ) Prior Year-End IBNR Loss and LAE Reserves Developed (Savings)/ Deficiency (Cols. 5 + 8 + 9 minus Col. ) Prior Year-End Total Loss and LAE Reserve Developed (Savings)/ Deficiency (Cols. + ). 05 + Prior 5,5,76 8,47,506,50 5,007,507 90 (540),57,76 (,85) (6). 06 5,50 8,594 4,096 7,780 864 8,644,665 407,88 5,460 5,94 (5,95) 8. Subtotals 06 + prior 0,75,770,5,86,65,65 7,7 797 848 8,87 7,705 (7,760) (55) 4. 07,4,05,548,85,48 4,79 8,79 977 8,879 8,647 0,99 (0,0) 78 5. Subtotals 07 + prior,996 4,075 65,07 4,7,79 7,90 5,96,774 9,77 7,464 8,04 (7,78) 4 6. 08 XXX XXX XXX XXX,556,556 XXX 8,567 8,595 7,6 XXX XXX XXX 7. Totals,996 4,075 65,07 4,7 7,49 5,486 5,96 0,4 8, 54,66 8,04 (7,78) Prior Year-End 8. Surplus As Col., Line 7 Col., Line 7 Col., Line 7 Regards Policyholders 9,74 Line 7 Line 7 Line As % of Col., As % of Col., As % of Col., 7. 7.8. (64.5). 0.5 Col., Line 7 Line 8 4..
SUPPLEMENTAL EXHIBITS AND SCHEDULES INTERROGATORIES 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. Response. Will the Trusteed Surplus Statement be filed with the state of domicile and the NAIC with this statement? NO. Will Supplement A to Schedule T (Medical Professional Liability Supplement) be filed with this statement? NO. Will the Medicare Part D Coverage Supplement be filed with the state of domicile and the NAIC with this statement? NO 4. Will the Director and Officer Insurance Coverage Supplement be filed with the state of domicile and the NAIC with this statement? NO Explanation:... 4. Bar Code:. *4897084900000*. *4897084550000*. *489708650000* 4. *4897085050000* 5
OVERFLOW PAGE FOR WRITE-INS PQ00 Additional Aggregate Lines for Page 0 Line 5. *ASSETS Assets Nonadmitted Assets Net Admitted Assets (Cols. - ) 4 December Prior Year Net Admitted Assets 504. Prepaid expenses 0, 0, 0 0 505. Deposits 8,99 8,99 0 0 506. Contribution of afiliated stock from parent 0 9,5,606 507. 0 0 508. 0 0 509. 0 0 597. Summary of remaining write-ins for Line 5 from Page 0 9,50 9,50 0 9,5,606 PQ00 Additional Aggregate Lines for Page 0 Line 5. *LIAB Current Statement Date December, Prior Year 504. Premium deficiency reserve 4,6 9,445 505. Retroactive reinsurance reserve assumed (64,6) (6,60) 506. 0 597. Summary of remaining write-ins for Line 5 from Page 0 (50,486) (44,56) 6
SCHEDULE A VERIFICATION Real Estate Prior Year Ended Year To Date December. Book/adjusted carrying value, December of prior year 4,000 4,000. Cost of acquired:. Actual cost at time of acquisition 0. Additional investment made after acquisition 0. Current year change in encumbrances 0 4. Total gain (loss) on disposals 0 5. Deduct amounts received on disposals 0 6. Total foreign exchange change in book/adjusted carrying value 0 7. Deduct current year s other-than-temporary impairment recognized 0 8. Deduct current year s depreciation 0 9. Book/adjusted carrying value at the end of current period (Lines +++4-5+6-7-8) 4,000 4,000 0. Deduct total nonadmitted amounts 4,000 4,000. Statement value at end of current period (Line 9 minus Line 0) 0 0 SCHEDULE B VERIFICATION Mortgage Loans Prior Year Ended Year To Date December. Book value/recorded investment excluding accrued interest, December of prior year 4,00,000 4,00,000. Cost of acquired:. Actual cost at time of acquisition 0. Additional investment made after acquisition 0. Capitalized deferred interest and other 0 4. Accrual of discount 0 5. Unrealized valuation increase (decrease) 0 6. Total gain (loss) on disposals 0 7. Deduct amounts received on disposals 9,66 0 8. Deduct amortization of premium and mortgage interest points and commitment fees 0 9. Total foreign exchange change in book value/recorded investment excluding accrued interest 0 0. Deduct current year s other-than-temporary impairment recognized 0. Book value/recorded investment excluding accrued interest at end of current period (Lines +++4+5+6-7- 8+9-0) 4,60,84 4,00,000. Total valuation allowance 0. Subtotal (Line plus Line ) 4,60,84 4,00,000 4. Deduct total nonadmitted amounts 0 0 5. Statement value at end of current period (Line minus Line 4) 4,60,84 4,00,000 SCHEDULE BA VERIFICATION Other Long-Term Invested Assets Prior Year Ended Year To Date December. Book/adjusted carrying value, December of prior year 0,796,409 4,7,686. Cost of acquired:. Actual cost at time of acquisition 9,5,606 0. Additional investment made after acquisition 08,000 56,097. Capitalized deferred interest and other 0 4. Accrual of discount 0 5. Unrealized valuation increase (decrease) 8,48,66 89,969 6. Total gain (loss) on disposals 56,048 5,90 7. Deduct amounts received on disposals,60,5 4,809,54 8. Deduct amortization of premium and depreciation 0 9. Total foreign exchange change in book/adjusted carrying value 0 0. Deduct current year s other-than-temporary impairment recognized 0. Book/adjusted carrying value at end of current period (Lines +++4+5+6-7-8+9-0) 45,90,78 0,796,409. Deduct total nonadmitted amounts 0 0. Statement value at end of current period (Line minus Line ) 45,90,78 0,796,409 SCHEDULE D VERIFICATION Bonds and Stocks Prior Year Ended Year To Date December. Book/adjusted carrying value of bonds and stocks, December of prior year 68,4,048 70,977,749. Cost of bonds and stocks acquired 8,955,800,49,689. Accrual of discount 4,809 8,5 4. Unrealized valuation increase (decrease) (7,0) (4,60) 5. Total gain (loss) on disposals 477,8 870,54 6. Deduct consideration for bonds and stocks disposed of,468,85 5,94,945 7. Deduct amortization of premium 9,4 77,67 8. Total foreign exchange change in book/adjusted carrying value 0 9. Deduct current year s other-than-temporary impairment recognized 0 0. Total investment income recognized as a result of prepayment penalties and/or acceleration fees. Book/adjusted carrying value at end of current period (Lines +++4+5-6-7+8-9+0) 46,074, 68,4,048. Deduct total nonadmitted amounts 0 0. Statement value at end of current period (Line minus Line ) 46,074, 68,4,048 SI0
SCHEDULE D - PART B Showing the Acquisitions, Dispositions and Non-Trading Activity During the Current Quarter for all Bonds and Preferred Stock by NAIC Designation NAIC Designation Book/Adjusted Carrying Value Beginning of Current Quarter Acquisitions During Current Quarter Dispositions During Current Quarter 4 Non-Trading Activity During Current Quarter 5 Book/Adjusted Carrying Value End of First Quarter 6 Book/Adjusted Carrying Value End of Second Quarter 7 Book/Adjusted Carrying Value End of Third Quarter 8 Book/Adjusted Carrying Value December Prior Year BONDS. NAIC (a),69,40 7,85,70,8,994 (46,05) 4,899,8,69,40 7,8, 47,06,940. NAIC (a) 5,805,996 75,000 (4,080) 7,696,550 5,805,996 5,487,96,868,76. NAIC (a) 46,677 00,8 5,80 4,59 46,677 568,69 00,948 4. NAIC 4 (a) 0 0 0 0 0 5. NAIC 5 (a) 0 0 0 0 0 6. NAIC 6 (a) 0 0 0 0 0 7. Total Bonds 9,9,9 7,85,70,94, (7,05) 4,007,45 9,9,9 4,867,746 59,986,649 SI0 PREFERRED STOCK 8. NAIC 0 0 0 0 0 9. NAIC 0 0 0 0 0 0. NAIC 0 0 0 0 0. NAIC 4 0 0 0 0 0. NAIC 5 0 0 0 0 0. NAIC 6 0 0 0 0 0 4. Total Preferred Stock 0 0 0 0 0 0 0 0 5. Total Bonds & Preferred Stock 9,9,9 7,85,70,94, (7,05) 4,007,45 9,9,9 4,867,746 59,986,649 (a) Book/Adjusted Carrying Value column for the end of the current reporting period includes the following amount of short-term and cash equivalent bonds by NAIC designation: NAIC $,8,684 ; NAIC $ ; NAIC $ ; NAIC 4 $ ; NAIC 5 $ ; NAIC 6 $
SCHEDULE DA - PART Short-Term Investments Book/Adjusted Carrying Value Par Value Actual Cost 4 Interest Collected Year To Date 5 Paid for Accrued Interest Year To Date 999999,8,684 XXX,8,8 5,0 SCHEDULE DA - VERIFICATION Short-Term Investments Year To Date Prior Year Ended December. Book/adjusted carrying value, December of prior year 0,000,7. Cost of short-term investments acquired,8,8 0. Accrual of discount 56 0 4. Unrealized valuation increase (decrease) 0 5. Total gain (loss) on disposals 0 6. Deduct consideration received on disposals,000,7 7. Deduct amortization of premium 0 8. Total foreign exchange change in book/adjusted carrying value 0 9. Deduct current year s other-than-temporary impairment recognized 0 0. Book/adjusted carrying value at end of current period (Lines +++4+5-6-7+8-9),8,684 0. Deduct total nonadmitted amounts 0. Statement value at end of current period (Line 0 minus Line ),8,684 0 SI0
Schedule DB - Part A - Verification NONE Schedule DB - Part B - Verification NONE Schedule DB - Part C - Section NONE Schedule DB - Part C - Section NONE Schedule DB - Verification NONE SI04, SI05, SI06, SI07
SCHEDULE E PART VERIFICATION (Cash Equivalents) Year To Date Prior Year Ended December. Book/adjusted carrying value, December of prior year 8,69,569 0. Cost of cash equivalents acquired,80,4 8,69,994. Accrual of discount 0 4. Unrealized valuation increase (decrease) 0 5. Total gain (loss) on disposals 0 6. Deduct consideration received on disposals 9,546,70 45 7. Deduct amortization of premium 0 8. Total foreign exchange change in book/adjusted carrying value 0 9. Deduct current year s other than temporary impairment recognized 0 0. Book/adjusted carrying value at end of current period (Lines +++4+5-6-7+8-9) 46,09 8,69,569. Deduct total nonadmitted amounts 0. Statement value at end of current period (Line 0 minus Line ) 46,09 8,69,569 SI08
Description of Property City Location SCHEDULE A - PART Showing All Real Estate ACQUIRED AND ADDITIONS MADE During the Current Quarter 4 5 6 7 8 9 State Date Acquired Name of Vendor Actual Cost at Time of Acquisition Amount of Encumbrances Book/Adjusted Carrying Value Less Encumbrances Additional Investment Made After Acquisition 099999 Totals 0 0 0 0 E0 SCHEDULE A - PART Showing All Real Estate DISPOSED During the Quarter, Including Payments During the Final Year on Sales Under Contract Location 4 5 6 7 8 Changes in Book/Adjusted Carrying Value Less Encumbrances 4 5 6 7 8 9 0 Expended 9 0 for Additions, Permanent Improvements and Changes Book/Adjusted Carrying Value Less Current Current Year s Other Than Temporary Current Year s Total Change Total Foreign Exchange Book/Adjusted Carrying Value Less Foreign Exchange Gain Realized Total Gain Gross Income Earned Less Interest Taxes, Repairs Disposal in Encumbrances Year s Impairment Change in in B./A. C.V. Change in Encumbrances Amounts Received (Loss) on Gain(Loss) on (Loss) on Incurred on and Expenses Description of Property City State Date Name of Purchaser Actual Cost Encumbrances Prior Year Depreciation Recognized Encumbrances (-9-0) B./A. C. V. on Disposal During Year Disposal Disposal Disposal Encumbrances Incurred 099999 Totals
SCHEDULE B - PART Showing All Mortgage Loans ACQUIRED AND ADDITIONS MADE During the Current Quarter Location 4 5 6 7 8 9 Loan Number City State Loan Type Date Acquired Rate of Interest Actual Cost at Time of Acquisition Additional Investment Made After Acquisition Value of Land and Buildings 99999 Totals 0 0 0 E0 SCHEDULE B - PART Showing All Mortgage Loans DISPOSED, Transferred or Repaid During the Current Quarter Location 4 5 6 7 Change in Book Value/Recorded Investment 4 5 6 7 8 8 9 0 Book Value/Recorded Current Investment Year s Excluding Unrealized Current Other Than Capitalized Total Accrued Valuation Year s Temporary Deferred Change in Loan Date Disposal Interest Increase (Amortization)/ Impairment Interest and Book Value Type Acquired Date Prior Year (Decrease) Accretion Recognized Other (8+9-0+) Loan Number City State Consideration Mortgages with partial repayments Schaumburg IL S /0/06 4,00,000 0 84,8 84,8 0 099999 - Mortgages with partial repayments 4,00,000 0 0 0 0 0 0 84,8 84,8 0 0 0 Total Foreign Exchange Change in Book Value Book Value/Recorded Investment Excluding Accrued Interest on Disposal Foreign Exchange Gain (Loss) on Disposal Realized Gain (Loss) on Disposal Total Gain (Loss) on Disposal 0599999 Totals 4,00,000 0 0 0 0 0 0 84,8 84,8 0 0 0
SCHEDULE BA - PART Showing Other Long-Term Invested Assets ACQUIRED AND ADDITIONS MADE During the Current Quarter Location 5 6 7 8 9 0 4 Name of Date Type Actual Commitment Vendor or NAIC Originally and Cost at Time of Additional Investment Amount of for Additional Name or Description City State General Partner Designation Acquired Strategy Acquisition Made After Acquisition Encumbrances Investment CUSIP Identification Joint, Partnership or Limited Liability Company Interests that have the Underlying Characteristics - Other - Unaffiliated 000000-00-0 4490 Ventures II LP DE 4490 Ventures II LP 0/7/08 87,000 08,000,90,000 6.5 99999 - Joint, Partnership or Limited Liability Company Interests that have the Underlying Characteristics - Other - Unaffiliated 87,000 08,000 0,90,000 XXX Percentage of Ownership 4499999 Subtotals - Unaffiliated 87,000 08,000 0,90,000 XXX 4599999 Subtotals - Affiliated 0 0 0 0 XXX 4699999 Totals 87,000 08,000 0,90,000 XXX E0 SCHEDULE BA - PART Showing Other Long-Term Invested Assets DISPOSED, Transferred or Repaid During the Current Quarter Location 5 6 7 8 Change in Book/Adjusted Carrying Value 5 6 7 8 9 0 4 9 0 4 Book/ Current Current Book/Adjusted Adjusted Year s Year s Total Total Carrying Carrying Unrealized (Depreciation) Other Than Capitalized Change Foreign Value Foreign Realized Total CUSIP Identification Name or Description City State Name of Purchaser or Nature of Disposal Date Originally Acquired Disposal Date Value Less Encumbrances Prior Year Valuation Increase (Decrease) or (Amortization)/ Accretion Temporary Impairment Recognized Deferred Interest and Other in B./A.C.V. (9+0-+) Exchange Change in B./A.C.V. Less Encumbrances on Disposal Exchange Gain (Loss) Consideration on Disposal Gain (Loss) on Disposal Gain (Loss) on Disposal Investment Income Joint Venture, Partnership or Limited Liability Company Interests that have the Underlying Characteristics - Real Estate - Unaffiliated 000000-00-0 Oak Street Real Estate Capital Fund III, LP Chicago IL Oak Street Real Estate Capital Fund III 07/9/05 0 5,8 5,8 5,8 799999 - Joint Venture, Partnership or Limited Liability Company Interests that have the Underlying Characteristics - Real Estate - Unaffiliated 0 0 0 0 0 0 0 0 5,8 0 5,8 5,8 0 Joint, Partnership or Limited Liability Company Interests that have the Underlying Characteristics - Other - Unaffiliated 000000-00-0 Stilwell Activist Investments, L.P. New York NY Partial Return of Capital 0/0/04 08//08 87,84 0 87,84 87,84 0 99999 - Joint, Partnership or Limited Liability Company Interests that have the Underlying Characteristics - Other - Unaffiliated 87,84 0 0 0 0 0 0 87,84 87,84 0 0 0 0 Collateral Loans - Unaffiliated 000000-00-0 Secured convertible promissory note Mobile AL Parial payment //05 45 0 45 45 0 599999 - Collateral Loans - Unaffiliated 45 0 0 0 0 0 0 45 45 0 0 0 0 4499999 Subtotals - Unaffiliated 88,87 0 0 0 0 0 0 88,87 0,570 0 5,8 5,8 0 4599999 Subtotals - Affiliated 0 0 0 0 0 0 0 0 0 0 0 0 0 4699999 Totals 88,87 0 0 0 0 0 0 88,87 0,570 0 5,8 5,8 0