ASSETS Current Year Prior Year 1 2 3 4 Net Admitted Nonadmitted Assets Net Assets Assets (Cols. 1-2) Admitted Assets 1. Bonds (Schedule D)......172,616,281...0...172,616,281...121,441,254 2. Stocks (Schedule D): 2.1 Preferred stocks......0...0...0...0 2.2 Common stocks......0...0...0...0 3. Mortgage loans on real estate (Schedule B): 3.1 First liens......0...0...0...0 3.2 Other than first liens......0...0...0...0 4. Real estate (Schedule A): 4.1 Properties occupied by the company (less $...0 encumbrances)......1,761,514...0...1,761,514...1,809,569 4.2 Properties held for the production of income (less $...0 encumbrances)......0...0...0...0 4.3 Properties held for sale (less $...0 encumbrances)......0...0...0...0 5. Cash ($...35,618,157, Schedule E-Part 1), cash equivalents ($...0, Schedule E-Part 2) and short-term investments ($...39,117,215, Schedule DA)......74,735,372...0...74,735,372...3,419,906 6. Contract loans (including $...0 premium notes)......2,785,409...0...2,785,409...2,426,900 7. Derivatives (Schedule DB)......0...0...0...0 8. Other invested assets (Schedule BA)......0...0...0...0 9. Receivables for securities......500,000...500,000...0...0 10. Securities lending reinvested collateral assets (Schedule DL)......0...0...0...0 11. Aggregate write-ins for invested assets......0...0...0...0 12. Subtotals, cash and invested assets (Lines 1 to 11)......252,398,576...500,000...251,898,576...129,097,629 13. Title plants less $...0 charged off (for Title insurers only)......0...0...0...0 14. Investment income due and accrued......2,352,016...0...2,352,016...1,987,593 15. Premiums and considerations: 15.1 Uncollected premiums and agents' balances in the course of collection......33,116,040...3,416,125...29,699,915...19,951,924 15.2 Deferred premiums, agents' balances and installments booked but deferred and not yet due (including $...0 earned but unbilled premiums)......794,231...0...794,231...98,685 15.3 Accrued retrospective premiums......0...0...0...0 16. Reinsurance: 16.1 Amounts recoverable from reinsurers......11,023,051...0...11,023,051...357,440 16.2 Funds held by or deposited with reinsured companies......0...0...0...0 16.3 Other amounts receivable under reinsurance contracts......28,302,750...0...28,302,750...0 17. Amounts receivable relating to uninsured plans......0...0...0...0 18.1 Current federal and foreign income tax recoverable and interest thereon......0...0...0...0 18.2 Net deferred tax asset......20,703,435...3,061,341...17,642,094...0 19. Guaranty funds receivable or on deposit......11,338...0...11,338...14,005 20. Electronic data processing equipment and software......1,878,781...0...1,878,781...1,383,662 21. Furniture and equipment, including health care delivery assets ($...0)......4,921,403...4,921,403...0...0 22. Net adjustment in assets and liabilities due to foreign exchange rates......0...0...0...0 23. Receivables from parent, subsidiaries and affiliates......0...0...0...14,435,416 24. Health care ($...0) and other amounts receivable......15,247,856...15,247,856...0...0 25. Aggregate write-ins for other than invested assets......846,752...459,757...386,995...122,612 26. Total assets excluding Separate Accounts, Segregated Accounts and Protected Cell Accounts (Lines 12 to 25)......371,596,229...27,606,482...343,989,747...167,448,966 27. From Separate Accounts, Segregated Accounts and Protected Cell Accounts......0...0...0...0 28. TOTALS (Lines 26 and 27)......371,596,229...27,606,482...343,989,747...167,448,966 DETAILS OF WRITE-INS 1101.......0...0...0...0 1102.......0...0...0...0 1103.......0...0...0...0 1198. Summary of remaining write-ins for Line 11 from overflow page......0...0...0...0 1199. Totals (Lines 1101 thru 1103 plus 1198) (Line 11 above)......0...0...0...0 2501. Administrative Fees due on Reinsurance Assumed......0...0...0...114,245 2502. Admissable Prepaid Reinsurance Premiums......0...0...0...8,367 2503. Leasehold Improvements......459,167...459,167...0...0 2598. Summary of remaining write-ins for Line 25 from overflow page......387,585...590...386,995...0 2599. Totals (Lines 2501 thru 2503 plus 2598) (Line 25 above)......846,752...459,757...386,995...122,612 2
LIABILITIES, SURPLUS AND OTHER FUNDS 1 2 Current Year Prior Year 1. Aggregate reserve for life contracts $...29,730,743 (Exhibit 5, Line 9999999) less $...0 included in Line 6.3 (including $...0 Modco Reserve)......29,730,743...26,058,230 2. Aggregate reserve for accident and health contracts (including $...15,005,775 Modco Reserve)......46,729,698...29,943,745 3. Liability for deposit-type contracts (Exhibit 7, Line 14, Col. 1) (including $...0 Modco Reserve)......192,969...182,672 4. Contract claims: 4.1 Life (Exhibit 8, Part 1, Line 4.4, Col. 1 less sum of Cols. 9, 10 and 11)......656,208...605,925 4.2 Accident and health (Exhibit 8, Part 1, Line 4.4, sum of Cols. 9, 10 and 11)......53,025,242...35,769,455 5. Policyholders' dividends $...0 and coupons $...0 due and unpaid (Exhibit 4, Line 10)......0...0 6. Provision for policyholders' dividends and coupons payable in following calendar year - estimated amounts: 6.1 Dividends apportioned for payment (including $...0 Modco)......0...0 6.2 Dividends not yet apportioned (including $...0 Modco)......0...0 6.3 Coupons and similar benefits (including $...0 Modco)......0...0 7. Amount provisionally held for deferred dividend policies not included in Line 6......0...0 8. Premiums and annuity considerations for life and accident and health contracts received in advance less $...0 discount; including $...71,677 accident and health premiums (Exhibit 1, Part 1, Col. 1, sum of Lines 4 and 14)......74,025...111,429 9. Contract liabilities not included elsewhere: 9.1 Surrender values on canceled contracts......0...0 9.2 Provision for experience rating refunds, including the liability of $...0 accident and health experience rating refunds of which $...0 is for medical loss ratio rebate per the Public Health Service Act......94,935...103,637 9.3 Other amounts payable on reinsurance, including $...0 assumed and $...32,236,540 ceded......32,236,540...2,736,034 9.4 Interest Maintenance Reserve (IMR, Line 6)......191,622...0 10. Commissions to agents due or accrued - life and annuity contracts $...246,103, accident and health $...15,779,979 and deposit-type contract funds $...0......16,026,082...7,547,504 11. Commissions and expense allowances payable on reinsurance assumed......859,591...1,032,061 12. General expenses due or accrued (Exhibit 2, Line 12, Col. 6)......7,193,294...8,280,981 13. Transfers to Separate Accounts due or accrued (net) (including $...0 accrued for expense allowances recognized in reserves, net of reinsured allowances)......0...0 14. Taxes, licenses and fees due or accrued, excluding federal income taxes (Exhibit 3, Line 9, Col. 5)......2,705,809...1,577,806 15.1 Current federal and foreign income taxes, including $...0 on realized capital gains (losses)......46,841...46,841 15.2 Net deferred tax liability......0...0 16. Unearned investment income......0...0 17. Amounts withheld or retained by company as agent or trustee......7,676...17,563 18. Amounts held for agents' account, including $...0 agents' credit balances......0...0 19. Remittances and items not allocated......11,976,542...14,991,217 20. Net adjustment in assets and liabilities due to foreign exchange rates......0...0 21. Liability for benefits for employees and agents if not included above......0...0 22. Borrowed money $...0 and interest thereon $...0......0...0 23. Dividends to stockholders declared and unpaid......0...0 24. Miscellaneous liabilities: 24.01 Asset valuation reserve (AVR Line 16, Col. 7)......496,648...348,169 24.02 Reinsurance in unauthorized and certified ($...0) companies......0...0 24.03 Funds held under reinsurance treaties with unauthorized and certified ($...0) reinsurers......0...0 24.04 Payable to parent, subsidiaries and affiliates......4,180,484...1,952,159 24.05 Drafts outstanding......0...0 24.06 Liability for amounts held under uninsured plans......0...0 24.07 Funds held under coinsurance......0...0 24.08 Derivatives......0...0 24.09 Payable for securities......0...0 24.10 Payable for securities lending......0...0 24.11 Capital notes $...0 and interest thereon $...0......0...0 25. Aggregate write-ins for liabilities......211,911...145,113 26. Total liabilities excluding Separate Accounts business (Lines 1 to 25)......206,636,860...131,450,541 27. From Separate Accounts Statement......0...0 28. Total liabilities (Line 26 and 27)......206,636,860...131,450,541 29. Common capital stock......2,500,000...2,500,000 30. Preferred capital stock......300,000...300,000 31. Aggregate write-ins for other than special surplus funds......19,074,900...0 32. Surplus notes......50,000,000...0 33. Gross paid in and contributed surplus (Page 3, Line 33, Col. 2 plus Page 4, Line 51.1, Col. 1)......82,437,395...57,437,395 34. Aggregate write-ins for special surplus funds......0...0 35. Unassigned funds (surplus)......(16,959,408)...(24,238,970) 36. Less treasury stock, at cost: 36.1...0.000 shares common (value included in Line 29 $...0)......0...0 36.2...0.000 shares preferred (value included in Line 30 $...0)......0...0 37. Surplus (Total Lines 31 + 32 + 33 + 34 + 35-36) (including $...0 in Separate Accounts Statement)......134,552,887...33,198,425 38. Totals of Lines 29, 30 and 37 (Page 4, Line 55)......137,352,887...35,998,425 39. Totals of Lines 28 and 38 (Page 2, Line 28, Col. 3)......343,989,747...167,448,966 DETAILS OF WRITE-INS 2501. Unclaimed Funds Liability......211,911...145,113 2502.......0...0 2503.......0...0 2598. Summary of remaining write-ins for Line 25 from overflow page......0...0 2599. Totals (Lines 2501 thru 2503 plus 2598) (Line 25 above)......211,911...145,113 3101. Ceding Allowance Modco Reinsurance......19,074,900...0 3102.......0...0 3103.......0...0 3198. Summary of remaining write-ins for Line 31 from overflow page......0...0 3199. Totals (Lines 3101 thru 3103 plus 3198) (Line 31 above)......19,074,900...0 3401.......0...0 3402.......0...0 3403.......0...0 3498. Summary of remaining write-ins for Line 34 from overflow page......0...0 3499. Totals (Lines 3401 thru 3403 plus 3498) (Line 34 above)......0...0 3
SUMMARY OF OPERATIONS 1 2 Current Year Prior Year 1. Premiums and annuity considerations for life and accident and health contracts (Exhibit 1, Part 1, Line 20.4, Col. 1, less Col. 11)......183,744,554...162,644,738 2. Considerations for supplementary contracts with life contingencies......0...0 3. Net investment income (Exhibit of Net Investment Income, Line 17)......6,237,938...4,488,739 4. Amortization of Interest Maintenance Reserve (IMR) (Line 5)......78,502...(20,018) 5. Separate Accounts net gain from operations excluding unrealized gains or losses......0...0 6. Commissions and expense allowances on reinsurance ceded (Exhibit 1, Part 2, Line 26.1, Col. 1)......79,885,334...449 7. Reserve adjustments on reinsurance ceded......14,473,736...0 8. Miscellaneous Income: 8.1 Income from fees associated with investment management, administration and contract guarantees from Separate Accounts......0...0 8.2 Charges and fees for deposit-type contracts......0...0 8.3 Aggregate write-ins for miscellaneous income......1,446,176...2,176,466 9. Totals (Lines 1 to 8.3)......285,866,240...169,290,374 10. Death benefits......2,750,153...1,893,202 11. Matured endowments (excluding guaranteed annual pure endowments)......0...0 12. Annuity benefits (Exhibit 8, Part 2, Line 6.4, Cols. 4 + 8)......0...0 13. Disability benefits and benefits under accident and health contracts......84,451,337...67,915,597 14. Coupons, guaranteed annual pure endowments and similar benefits......0...0 15. Surrender benefits and withdrawals for life contracts......798,233...645,646 16. Group conversions......0...0 17. Interest and adjustments on contract or deposit-type contract funds......10,296...1,050 18. Payments on supplementary contracts with life contingencies......0...0 19. Increase in aggregate reserves for life and accident and health contracts......20,458,466...8,699,282 20. Totals (Lines 10 to 19)......108,468,485...79,154,777 21. Commissions on premiums, annuity considerations and deposit-type contract funds (direct business only) (Exhibit 1, Part 2, Line 31, Col. 1)......115,789,763...61,658,145 22. Commissions and expense allowances on reinsurance assumed (Exhibit 1, Part 2, Line 26.2, Col. 1)......5,883,922...6,760,602 23. General insurance expenses (Exhibit 2, Line 10, Columns 1, 2, 3 and 4)......67,656,332...47,841,122 24. Insurance taxes, licenses and fees, excluding federal income taxes (Exhibit 3, Line 7, Cols. 1 + 2 + 3)......9,016,057...6,576,964 25. Increase in loading on deferred and uncollected premiums......0...(14,452) 26. Net transfers to or (from) Separate Accounts net of reinsurance......0...0 27. Aggregate write-ins for deductions......208,439...103,637 28. Totals (Lines 20 to 27)......307,022,998...202,080,795 29. Net gain from operations before dividends to policyholders and federal income taxes (Line 9 minus Line 28)......(21,156,759)...(32,790,421) 30. Dividends to policyholders......0...0 31. Net gain from operations after dividends to policyholders and before federal income taxes (Line 29 minus Line 30)......(21,156,759)...(32,790,421) 32. Federal and foreign income taxes incurred (excluding tax on capital gains)......0...(342,727) 33. Net gain from operations after dividends to policyholders and federal income taxes and before realized capital gains or (losses) (Line 31 minus Line 32)......(21,156,759)...(32,447,694) 34. Net realized capital gains (losses) (excluding gains (losses) transferred to the IMR) less capital gains tax of $...0 (excluding taxes of $...0 transferred to the IMR)......0...0 35. Net income (Line 33 plus Line 34)......(21,156,759)...(32,447,694) CAPITAL AND SURPLUS ACCOUNT 36. Capital and surplus, December 31, prior year (Page 3, Line 38, Col. 2)......35,998,425...31,541,192 37. Net income (Line 35)......(21,156,759)...(32,447,694) 38. Change in net unrealized capital gains (losses) less capital gains tax of $...0......0...0 39. Change in net unrealized foreign exchange capital gain (loss)......0...0 40. Change in net deferred income tax......14,550,194...13,637,557 41. Change in nonadmitted assets......9,163,241...(32,953,391) 42. Change in liability for reinsurance in unauthorized and certified companies......0...0 43. Change in reserve on account of change in valuation basis, (increase) or decrease (Exhibit 5A, Line 9999999, Col. 4)......0...(1,465,000) 44. Change in asset valuation reserve......(148,479)...(69,896) 45. Change in treasury stock, (Page 3, Lines 36.1 and 36.2 Col. 2 minus Col. 1)......0...0 46. Surplus (contributed to) withdrawn from Separate Accounts during period......0...0 47. Other changes in surplus in Separate Accounts Statement......0...0 48. Change in surplus notes......50,000,000...0 49. Cumulative effect of changes in accounting principles......4,871,365...0 50. Capital changes: 50.1 Paid in......0...0 50.2 Transferred from surplus (Stock Dividend)......0...0 50.3 Transferred to surplus......0...0 51. Surplus adjustment: 51.1 Paid in......25,000,000...55,000,000 51.2 Transferred to capital (Stock Dividend)......0...0 51.3 Transferred from capital......0...0 51.4 Change in surplus as a result of reinsurance......19,074,900...0 52. Dividends to stockholders......0...0 53. Aggregate write-ins for gains and losses in surplus......0...2,755,657 54. Net change in capital and surplus for the year (Lines 37 through 53)......101,354,462...4,457,233 55. Capital and surplus, December 31, current year (Lines 36 + 54) (Page 3, Line 38)......137,352,887...35,998,425 DETAILS OF WRITE-INS 08.301. Administrative Fees on Reinsurance Assumed......950,812...1,877,618 08.302. Other Miscellaneous......1,648,406...298,848 08.303. Investment Income Modco......(1,153,042)...0 08.398. Summary of remaining write-ins for Line 8.3 from overflow page......0...0 08.399. Totals (Lines 08.301 thru 08.303 plus 08.398) (Line 8.3 above)......1,446,176...2,176,466 2701. Experience Refund......203,995...103,637 2702. Loss on Sale of Fixed Assets......4,444...0 2703.......0...0 2798. Summary of remaining write-ins for Line 27 from overflow page......0...0 2799. Totals (Lines 2701 thru 2703 plus 2798) (Line 27 above)......208,439...103,637 5301. State Examination Audit Adjustment......0...2,755,657 5302.......0...0 5303.......0...0 5398. Summary of remaining write-ins for Line 53 from overflow page......0...0 5399. Totals (Lines 5301 thru 5303 plus 5398) (Line 53 above)......0...2,755,657 4
CASH FROM OPERATIONS CASH FLOW 1 2 Current Year Prior Year 1. Premiums collected net of reinsurance......176,747,768...151,807,965 2. Net investment income......6,680,328...4,282,010 3. Miscellaneous income......95,805,246...2,176,915 4. Total (Lines 1 through 3)......279,233,342...158,266,890 5. Benefit and loss related payments......84,316,428...56,484,388 6. Net transfers to Separate Accounts, Segregated Accounts and Protected Cell Accounts......0...0 7. Commissions, expenses paid and aggregate write-ins for deductions......190,150,501...111,956,278 8. Dividends paid to policyholders......0...0 9. Federal and foreign income taxes paid (recovered) net of $...0 tax on capital gains (losses)......0...0 10. Total (Lines 5 through 9)......274,466,929...168,440,666 11. Net cash from operations (Line 4 minus Line 10)......4,766,413...(10,173,776) CASH FROM INVESTMENTS 12. Proceeds from investments sold, matured or repaid: 12.1 Bonds......8,098,018...18,187,595 12.2 Stocks......0...911,978 12.3 Mortgage loans......0...0 12.4 Real estate......0...0 12.5 Other invested assets......0...0 12.6 Net gains or (losses) on cash, cash equivalents and short-term investments......0...0 12.7 Miscellaneous proceeds......0...0 12.8 Total investment proceeds (Lines 12.1 to 12.7)......8,098,018...19,099,573 13. Cost of investments acquired (long-term only): 13.1 Bonds......59,716,147...61,885,305 13.2 Stocks......0...21,713 13.3 Mortgage loans......0...0 13.4 Real estate......0...0 13.5 Other invested assets......0...0 13.6 Miscellaneous applications......0...0 13.7 Total investments acquired (Lines 13.1 to 13.6)......59,716,147...61,907,018 14. Net increase (decrease) in contract loans and premium notes......250,518...468,997 15. Net cash from investments (Line 12.8 minus Lines 13.7 minus Line 14)......(51,868,647)...(43,276,442) 16. Cash provided (applied): CASH FROM FINANCING AND MISCELLANEOUS SOURCES 16.1 Surplus notes, capital notes......50,000,000...0 16.2 Capital and paid in surplus, less treasury stock......25,000,000...55,000,000 16.3 Borrowed funds......0...0 16.4 Net deposits on deposit-type contracts and other insurance liabilities......1,384...0 16.5 Dividends to stockholders......0...0 16.6 Other cash provided (applied)......43,416,316...(19,476,492) 17. Net cash from financing and miscellaneous sources (Lines 16.1 to 16.4 minus Line 16.5 plus Line 16.6)......118,417,700...35,523,508 RECONCILIATION OF CASH, CASH EQUIVALENTS AND SHORT-TERM INVESTMENTS 18. Net change in cash, cash equivalents and short-term investments (Line 11 plus Line 15 plus Line 17)......71,315,466...(17,926,710) 19. Cash, cash equivalents and short-term investments: 19.1 Beginning of year......3,419,906...21,346,616 19.2 End of year (Line 18 plus Line 19.1)......74,735,372...3,419,906 Note: Supplemental disclosures of cash flow information for non-cash transactions: 20.0001......0...0 5
6 Annual Statement for the year 2012 of the ANALYSIS OF OPERATIONS BY LINES OF BUSINESS 1 2 Ordinary 6 Group Accident and Health 12 3 4 5 Credit Life 7 8 9 10 11 Aggregate of Industrial Life Individual Supplementary (Group and Life Credit (Group All Other Lines Total Life Insurance Annuities Contracts Individual) Insurance(a) Annuities Group and Individual) Other of Business 1. Premiums and annuity considerations for life and accident and health contracts......183,744,554...0...385,940...319...0...0...13,134,694...0...169,597,465...0...626,136...0 2. Considerations for supplementary contracts with life contingencies......0...0...0...0...0...0...0...0...0...0...0...0 3. Net investment income......6,237,938...0...13,102...0...0...0...445,910...0...5,757,669...0...21,257...0 4. Amortization of Interest Maintenance Reserve (IMR)......78,501...0...1,001...0...0...0...16,755...0...59,812...0...933...0 5. Separate Accounts net gain from operations excluding unrealized gains or losses......0...0...0...0...0...0...0...0...0...0...0...0 6. Commissions and expense allowances on reinsurance ceded......79,885,334...0...0...0...0...0...0...0...79,872,074...0...13,260...0 7. Reserve adjustments on reinsurance ceded......14,473,736...0...0...0...0...0...0...0...14,474,909...0...(1,174)...0 8. Miscellaneous Income: 8.1 Fees associated with income from investment management, administration and contract guarantees from S/A......0...0...0...0...0...0...0...0...0...0...0...0 8.2 Charges and fees for deposit-type contracts......0...0...0...0...0...0...0...0...0...0...0...0 8.3 Aggregate write-ins for miscellaneous income......1,446,176...0...33,156...0...0...0...554,767...0...827,353...0...30,900...0 9. Totals (Lines 1 to 8.3)......285,866,239...0...433,199...319...0...0...14,152,126...0...270,589,282...0...691,312...0 10. Death benefits......2,750,153...0...89,467...0...0...0...2,660,686...0...0...0...0...0 11. Matured endowments (excluding guaranteed annual pure endowments)......0...0...0...0...0...0...0...0...0...0...0...0 12. Annuity benefits......0...0...0...0...0...0...0...0...0...0...0...0 13. Disability benefits and benefits under accident and health contracts......84,451,338...0...0...0...0...0...0...0...84,250,496...0...200,842...0 14. Coupons, guaranteed annual pure endowments and similar benefits......0...0...0...0...0...0...0...0...0...0...0...0 15. Surrender benefits and withdrawals for life contracts......798,233...0...74,140...0...0...0...724,093...0...0...0...0...0 16. Group conversions......0...0...0...0...0...0...0...0...0...0...0...0 17. Interest and adjustments on contract or deposit-type contract funds......10,296...0...0...10,296...0...0...0...0...0...0...0...0 18. Payments on supplementary contracts with life contingencies......0...0...0...0...0...0...0...0...0...0...0...0 19. Increase in aggregate reserves for life and accident and health contracts......20,458,466...0...16,641...0...0...0...3,655,872...0...16,870,617...0...(84,664)...0 20. Totals (Lines 10 to 19)......108,468,486...0...180,247...10,296...0...0...7,040,651...0...101,121,113...0...116,178...0 21. Commissions on premiums, annuity considerations and deposit-type contract funds (direct business only)......115,789,763...0...17,077...0...0...0...4,698,362...0...110,967,935...0...106,388...0 22. Commissions and expense allowances on reinsurance assumed......5,883,922...0...0...0...0...0...19,949...0...5,871,546...0...(7,573)...0 23. General insurance expenses......67,656,331...0...108,742...0...0...0...3,700,820...0...63,611,921...0...234,848...0 24. Insurance taxes, licenses and fees, excluding federal income taxes......9,016,056...0...14,649...0...0...0...498,561...0...8,471,570...0...31,276...0 25. Increase in loading on deferred and uncollected premiums......0...0...0...0...0...0...0...0...0...0...0...0 26. Net transfers to or (from) Separate Accounts net of reinsurance......0...0...0...0...0...0...0...0...0...0...0...0 27. Aggregate write-ins for deductions......208,439...0...0...0...0...0...0...0...0...0...208,439...0 28. Totals (Lines 20 to 27)......307,022,997...0...320,715...10,296...0...0...15,958,343...0...290,044,085...0...689,556...0 29. Net gain from operations before dividends to policyholders and federal income taxes (Line 9 minus Line 28)......(21,156,758)...0...112,484...(9,977)...0...0...(1,806,217)...0...(19,454,803)...0...1,756...0 30. Dividends to policyholders......0...0...0...0...0...0...0...0...0...0...0...0 31. Net gain from operations after dividends to policyholders and before federal income taxes (Line 29 minus Line 30)......(21,156,758)...0...112,484...(9,977)...0...0...(1,806,217)...0...(19,454,803)...0...1,756...0 32. Federal income taxes incurred (excluding tax on capital gains)......0...0...0...0...0...0...0...0...0...0...0...0 33. Net gain from operations after dividends to policyholders and federal income taxes and before realized capital gains or (losses) (Line 31 minus Line 32)......(21,156,758)...0...112,484...(9,977)...0...0...(1,806,217)...0...(19,454,803)...0...1,756...0 DETAILS OF WRITE-INS 08.301. Administrative Fees on Reinsurance Assumed......950,812...0...12,129...0...0...0...202,938...0...724,442...0...11,303...0 08.302. Other Miscellaneous......1,648,406...0...21,027...0...0...0...351,829...0...1,255,953...0...19,597...0 08.303. Investment Income Modco......(1,153,042)...0...0...0...0...0...0...0...(1,153,042)...0...0...0 08.398. Summary of remaining write-ins for Line 8.3 from overflow page......0...0...0...0...0...0...0...0...0...0...0...0 08.399. Total (Lines 08.301 thru 08.303 plus 08.398) (Line 8.3 above)......1,446,176...0...33,156...0...0...0...554,767...0...827,353...0...30,900...0 2701. Experience Refund......203,995...0...0...0...0...0...0...0...0...0...203,995...0 2702. Loss on Sale of Fixed Assets......4,444...0...0...0...0...0...0...0...0...0...4,444...0 2703.......0...0...0...0...0...0...0...0...0...0...0...0 2798. Summary of remaining write-ins for Line 27 from overflow page......0...0...0...0...0...0...0...0...0...0...0...0 2799. Total (Lines 2701 thru 2703 plus 2798) (Line 27 above)......208,439...0...0...0...0...0...0...0...0...0...208,439...0 (a) Includes the following amounts for FEGLI/SGLI: Line 1...0 Line 10...0 Line 16...0 Line 23...0 Line 24...0.
Involving Life or Disability Contingencies (Reserves) (Net of Reinsurance Ceded) ANALYSIS OF INCREASE IN RESERVES DURING THE YEAR 1 2 Ordinary 6 Group 3 4 5 Credit Life 7 8 Industrial Supplementary (Group and Total Life Life Insurance Individual Annuities Contracts Individual) Life Insurance Annuities 1. Reserve December 31, prior year......26,058,230...0...3,920,644...0...0...0...22,137,586...0 2. Tabular net premiums or considerations......6,113,695...0...301,032...0...0...0...5,812,663...0 3. Present value of disability claims incurred......0...0...0...0...xxx......0...0...0 4. Tabular interest......1,123,256...0...160,445...0...0...0...962,811...0 5. Tabular less actual reserve released......0...0...0...0...0...0...0...0 6. Increase in reserve on account of change in valuation basis......0...0...0...0...0...0...0...0 7. Other increases (net)......0...0...0...0...0...0...0...0 8. Totals (Lines 1 to 7)......33,295,181...0...4,382,121...0...0...0...28,913,060...0 7 9. Tabular cost......1,211,609...0...210,522...0...xxx......0...1,001,087...0 10. Reserves released by death......285,463...0...114,222...xxx......xxx......0...171,241...xxx... 11. Reserves released by other terminations (net)......2,067,366...0...120,093...0...0...0...1,947,273...0 12. Annuity, supplementary contract, and disability payments involving life contingencies......0...0...0...0...0...0...0...0 13. Net transfers to or (from) Separate Accounts......0...0...0...0...0...0...0...0 14. Total deductions (Lines 9 to 13)......3,564,438...0...444,837...0...0...0...3,119,601...0 15. Reserve December 31, current year......29,730,743...0...3,937,284...0...0...0...25,793,459...0
EXHIBIT OF NET INVESTMENT INCOME 1 2 Collected Earned During Year During Year 1. U.S. government bonds... (a)...241,420...232,402 1.1 Bonds exempt from U.S. tax... (a)...0...0 1.2 Other bonds (unaffiliated)... (a)...5,484,155...5,853,255 1.3 Bonds of affiliates... (a)...0...0 2.1 Preferred stocks (unaffiliated)... (b)...0...0 2.11 Preferred stocks of affiliates... (b)...0...0 2.2 Common stocks (unaffiliated)......113...113 2.21 Common stocks of affiliates......0...0 3. Mortgage loans... (c)...0...0 4. Real estate... (d)...173,490...173,490 5. Contract loans......194,577...194,577 6. Cash, cash equivalents and short-term investments... (e)...24,132...28,471 7. Derivative instruments... (f)...0...0 8. Other invested assets......0...0 9. Aggregate write-ins for investment income......0...0 10. Total gross investment income......6,117,887...6,482,308 11. Investment expenses... (g)...165,270 12. Investment taxes, licenses and fees, excluding federal income taxes... (g)...31,045 13. Interest expense... (h)...0 14. Depreciation on real estate and other invested assets... (i)...48,055 15. Aggregate write-ins for deductions from investment income......0 16. Total deductions (Lines 11 through 15)......244,370 17. Net investment income (Line 10 minus Line 16)......6,237,938 DETAILS OF WRITE-INS 0901.......0...0 0902.......0...0 0903.......0...0 0998. Summary of remaining write-ins for Line 9 from overflow page......0...0 0999. Totals (Lines 0901 thru 0903 plus 0998) (Line 9 above)......0...0 1501.......0 1502.......0 1503.......0 1598. Summary of remaining write-ins for Line 15 from overflow page......0 1599. Totals (Lines 1501 thru 1503 plus 1598) (Line 15 above)......0 (a) Includes $...7,444 accrual of discount less $...754,325 amortization of premium and less $...327,529 paid for accrued interest on purchases. (b) Includes $...0 accrual of discount less $...0 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 $...0 paid for accrued interest on purchases. (d) Includes $...173,490 for company's occupancy of its own buildings; and excludes $...0 interest on encumbrances. (e) Includes $...0 accrual of discount less $...0 amortization of premium and less $...0 paid for accrued interest on purchases. (f) Includes $...0 accrual of discount less $...0 amortization of premium. (g) Includes $...0 investment expenses and $...0 investment taxes, licenses and fees, excluding federal income taxes, attributable to Segregated and Separate Accounts. (h) Includes $...0 interest on surplus notes and $...0 interest on capital notes. (i) Includes $...48,055 depreciation on real estate and $...0 depreciation on other invested assets. EXHIBIT OF CAPITAL GAINS (LOSSES) 1 2 3 4 5 Realized Change in Gain (Loss) Other Total Realized Change in Unrealized on Sales Realized Capital Gain (Loss) Unrealized Foreign Exchange or Maturity Adjustments (Columns 1 + 2) Capital Gain (Loss) Capital Gain (Loss) 1. U.S. government bonds......0...0...0...0...0 1.1 Bonds exempt from U.S. tax......0...0...0...0...0 1.2 Other bonds (unaffiliated)......303,779...0...303,779...0...0 1.3 Bonds of affiliates......0...0...0...0...0 2.1 Preferred stocks (unaffiliated)......0...0...0...0...0 2.11 Preferred stocks of affiliates......0...0...0...0...0 2.2 Common stocks (unaffiliated)......0...0...0...0...0 2.21 Common stocks of affiliates......0...0...0...0...0 3. Mortgage loans......0...0...0...0...0 4. Real estate......0...0...0...0...0 5. Contract loans......0...0...0...0...0 6. Cash, cash equivalents and short-term investments......0...0...0...0...0 7. Derivative instruments......0...0...0...0...0 8. Other invested assets......0...0...0...0...0 9. Aggregate write-ins for capital gains (losses)......0...0...0...0...0 10. Total capital gains (losses)......303,779...0...303,779...0...0 DETAILS OF WRITE-INS 0901.......0...0...0...0...0 0902.......0...0...0...0...0 0903.......0...0...0...0...0 0998. Summary of remaining write-ins for Line 9 from overflow page......0...0...0...0...0 0999. Totals (Lines 0901 thru 0903 plus 0998) (Line 9 above)......0...0...0...0...0 8
9 Annual Statement for the year 2012 of the EXHIBIT 1 - PART 1 - PREMIUMS AND ANNUITY CONSIDERATIONS FOR LIFE AND ACCIDENT AND HEALTH CONTRACTS 1 2 Ordinary 5 Group Accident and Health 11 3 4 Credit Life 6 7 8 9 10 Aggregate of Industrial Individual (Group and Credit All Other Lines Total Life Life Insurance Annuities Individual) Life Insurance Annuities Group (Group & Individual) Other of Business FIRST YEAR (other than single) 1. Uncollected......15,306,684...0...353...0...0...248,405...0...15,057,445...0...481...0 2. Deferred and accrued......0...0...0...0...0...0...0...0...0...0...0 3. Deferred, accrued and uncollected: 3.1 Direct......15,119,527...0...353...0...0...247,561...0...14,871,129...0...484...0 3.2 Reinsurance assumed......187,160...0...0...0...0...844...0...186,316...0...0...0 3.3 Reinsurance ceded......0...0...0...0...0...0...0...0...0...0...0 3.4 Net (Line 1 + Line 2)......15,306,684...0...353...0...0...248,405...0...15,057,445...0...481...0 4. Advance......0...0...0...0...0...0...0...0...0...0...0 5. Line 3.4 - Line 4......15,306,684...0...353...0...0...248,405...0...15,057,445...0...481...0 6. Collected during year: 6.1 Direct......154,509,475...0...14,148...0...0...4,646,977...0...149,840,104...0...8,246...0 6.2 Reinsurance assumed......3,273,974...0...0...0...0...17,708...0...3,256,266...0...0...0 6.3 Reinsurance ceded......59,846,239...0...0...0...0...0...0...59,846,203...0...36...0 6.4 Net......97,937,210...0...14,148...0...0...4,664,685...0...93,250,167...0...8,210...0 7. Line 5 + Line 6.4......113,243,894...0...14,501...0...0...4,913,090...0...108,307,612...0...8,691...0 8. Prior year (uncollected + deferred and accrued - advance)......13,707,246...0...2,629...0...0...193,174...0...13,507,164...0...4,279...0 9. First year premiums and considerations: 9.1 Direct......157,093,526...0...11,872...0...0...4,706,181...0...152,368,008...0...7,465...0 9.2 Reinsurance assumed......3,096,020...0...0...0...0...13,735...0...3,085,306...0...(3,021)...0 9.3 Reinsurance ceded......60,652,897...0...0...0...0...0...0...60,652,866...0...31...0 9.4 Net (Line 7 - Line 8)......99,536,648...0...11,872...0...0...4,719,916...0...94,800,448...0...4,412...0 SINGLE 10. Single premiums and considerations: 10.1 Direct......0...0...0...0...0...0...0...0...0...0...0 10.2 Reinsurance assumed......0...0...0...0...0...0...0...0...0...0...0 10.3 Reinsurance ceded......0...0...0...0...0...0...0...0...0...0...0 10.4 Net......0...0...0...0...0...0...0...0...0...0...0 RENEWAL 11. Uncollected......14,393,229...0...5,841...94...0...234,616...0...14,129,200...0...23,478...0 12. Deferred and accrued......794,231...0...107,055...0...0...687,176...0...0...0...0...0 13. Deferred, accrued and uncollected: 13.1 Direct......14,094,695...0...112,896...94...0...914,332...0...13,043,895...0...23,478...0 13.2 Reinsurance assumed......1,092,766...0...0...0...0...7,461...0...1,085,305...0...0...0 13.3 Reinsurance ceded......0...0...0...0...0...0...0...0...0...0...0 13.4 Net (Line 11 + Line 12)......15,187,460...0...112,896...94...0...921,792...0...14,129,200...0...23,478...0 14. Advance......74,025...0...1,279...0...0...1,069...0...69,816...0...1,861...0 15. Line 13.4 - Line 14......15,113,435...0...111,617...94...0...920,723...0...14,059,384...0...21,617...0 16. Collected during year: 16.1 Direct......108,028,186...0...300,981...225...0...8,413,809...0...98,629,947...0...683,224...0 16.2 Reinsurance assumed......10,852,729...0...0...0...0...83,956...0...10,757,189...0...11,584...0 16.3 Reinsurance ceded......40,070,359...0...11,462...0...0...814,028...0...39,209,254...0...35,615...0 16.4 Net......78,810,556...0...289,519...225...0...7,683,737...0...70,177,882...0...659,193...0 17. Line 15 + Line 16.4......93,923,991...0...401,136...319...0...8,604,460...0...84,237,266...0...680,810...0 18. Prior year (uncollected + deferred and accrued - advance)......9,716,085...0...27,068...0...0...189,682...0...9,440,249...0...59,086...0 19. Renewal premiums and considerations: 19.1 Direct......117,197,565...0...385,531...318...0...9,153,938...0...106,997,609...0...660,169...0 19.2 Reinsurance assumed......10,418,666...0...0...0...0...74,869...0...10,347,487...0...(3,690)...0 19.3 Reinsurance ceded......43,408,325...0...11,462...0...0...814,028...0...42,548,079...0...34,756...0 19.4 Net (Line 17 - Line 18)......84,207,906...0...374,068...319...0...8,414,778...0...74,797,017...0...621,724...0 TOTAL 20. Total premiums and annuity considerations: 20.1 Direct......274,291,091...0...397,403...318...0...13,860,119...0...259,365,617...0...667,634...0 20.2 Reinsurance assumed......13,514,686...0...0...0...0...88,604...0...13,432,793...0...(6,711)...0 20.3 Reinsurance ceded......104,061,222...0...11,462...0...0...814,028...0...103,200,945...0...34,787...0 20.4 Net (Lines 9.4 + 10.4 + 19.4)......183,744,554...0...385,940...319...0...13,134,694...0...169,597,465...0...626,136...0
DIVIDENDS AND COUPONS APPLIED (included in Part 1) EXHIBIT 1 - PART 2 - DIVIDENDS AND COUPONS APPLIED, REINSURANCE COMMISSIONS AND EXPENSE ALLOWANCES AND COMMISSIONS INCURRED (direct business only) 1 2 Ordinary 5 Group Accident and Health 11 3 4 Credit Life 6 7 8 9 10 Aggregate of Industrial Individual (Group and Credit All Other Lines Total Life Life Insurance Annuities Individual) Life Insurance Annuities Group (Group & Individual) Other of Business 21. To pay renewal premiums......0...0...0...0...0...0...0...0...0...0...0 22. All other......0...0...0...0...0...0...0...0...0...0...0 10 REINSURANCE COMMISSIONS AND EXPENSE ALLOWANCES INCURRED 23. First year (other than single): 23.1 Reinsurance ceded......66,639,581...0...0...0...0...0...0...66,639,544...0...37...0 23.2 Reinsurance assumed......3,553,201...0...0...0...0...(23,925)...0...3,580,168...0...(3,042)...0 23.3 Net ceded less assumed......63,086,380...0...0...0...0...23,925...0...63,059,376...0...3,079...0 24. Single: 24.1 Reinsurance ceded......0...0...0...0...0...0...0...0...0...0...0 24.2 Reinsurance assumed......0...0...0...0...0...0...0...0...0...0...0 24.3 Net ceded less assumed......0...0...0...0...0...0...0...0...0...0...0 25. Renewal: 25.1 Reinsurance ceded......13,245,753...0...0...0...0...0...0...13,232,530...0...13,223...0 25.2 Reinsurance assumed......2,330,721...0...0...0...0...43,874...0...2,291,378...0...(4,531)...0 25.3 Net ceded less assumed......10,915,032...0...0...0...0...(43,874)...0...10,941,152...0...17,754...0 26. Totals: 26.1 Reinsurance ceded (Page 6, Line 6)......79,885,334...0...0...0...0...0...0...79,872,074...0...13,260...0 26.2 Reinsurance assumed (Page 6, Line 22)......5,883,922...0...0...0...0...19,949...0...5,871,546...0...(7,573)...0 26.3 Net ceded less assumed......74,001,412...0...0...0...0...(19,949)...0...74,000,528...0...20,833...0 COMMISSIONS INCURRED (direct business only) 27. First year (other than single)......103,394,610...0...5,827...0...0...4,311,550...0...99,073,313...0...3,920...0 28. Single......0...0...0...0...0...0...0...0...0...0...0 29. Renewal......12,395,153...0...11,250...0...0...386,812...0...11,894,622...0...102,468...0 30. Deposit-type contract funds......0...0...0...0...0...0...0...0...0...0...0 31. Totals (to agree with Page 6, Line 21)......115,789,763...0...17,077...0...0...4,698,362...0...110,967,935...0...106,388...0
EXHIBIT 2 - GENERAL EXPENSES Insurance 5 6 1 Accident and Health 4 2 3 All Other Lines Life Cost Containment All Other of Business Investment Total 1. Rent......138,406...0...2,340,411...0...(54,565)...2,424,252 2. Salaries and wages......1,779,350...0...29,983,254...0...142,528...31,905,132 3.11 Contributions for benefit plans for employees......236,002...0...4,077,603...0...2,391...4,315,996 3.12 Contributions for benefit plans for agents......6,348...0...116,892...0...0...123,240 3.21 Payments to employees under non-funded benefit plans......7,512...0...136,235...0...3,972...147,719 3.22 Payments to agents under non-funded benefit plans......0...0...0...0...0...0 3.31 Other employee welfare......37,373...0...643,061...0...158...680,592 3.32 Other agent welfare......0...0...0...0...0...0 4.1 Legal fees and expenses......8,421...0...150,409...0...596...159,426 4.2 Medical examination fees......281...0...5,232...0...0...5,513 4.3 Inspection report fees......1,780...0...29,896...0...0...31,676 4.4 Fees of public accountants and consulting actuaries......18,118...0...275,812...0...674...294,604 4.5 Expense of investigation and settlement of policy claims......10,236...0...163,055...0...0...173,291 5.1 Traveling expenses......50,209...0...854,098...0...757...905,064 5.2 Advertising......175,950...0...3,139,698...0...8...3,315,656 5.3 Postage, express, telegraph and telephone......130,666...0...2,174,891...0...136...2,305,693 5.4 Printing and stationery......43,546...0...714,227...0...25...757,798 5.5 Cost or depreciation of furniture and equipment......42,974...0...720,653...0...39...763,666 5.6 Rental of equipment......36,618...0...625,897...0...83...662,598 5.7 Cost or depreciation of EDP equipment and software......43,741...0...735,305...0...6...779,052 6.1 Books and periodicals......9,536...0...157,958...0...72...167,566 6.2 Bureau and association fees......1,111...0...20,433...0...42...21,586 6.3 Insurance, except on real estate......6,034...0...107,978...0...1,376...115,388 6.4 Miscellaneous losses......0...0...0...0...0...0 6.5 Collection and bank service charges......17,842...0...296,230...0...105...314,177 6.6 Sundry general expenses......327,526...0...5,477,289...0...5,339...5,810,154 6.7 Group service and administration fees......15,219...0...243,189...0...0...258,408 6.8 Reimbursements by uninsured plans......0...0...0...0...0...0 7.1 Agency expense allowance......869...0...16,007...0...0...16,876 7.2 Agents' balances charged off (less $...0 recovered)......1,095...0...20,165...0...0...21,260 7.3 Agency conferences other than local meetings......41,485...0...581,242...0...139...622,866 9.1 Real estate expenses......0...0...0...0...57,544...57,544 9.2 Investment expenses not included elsewhere......0...0...0...0...3,845...3,845 9.3 Aggregate write-ins for expenses......621,314...0...10,039,649...0...0...10,660,963 10. General expenses Incurred......3,809,562...0...63,846,769...0...165,270 (a)...67,821,601 11. General expenses unpaid December 31, prior year......606,384...0...7,667,324...0...7,273...8,280,981 12. General expenses unpaid December 31, current year......404,049...0...6,771,715...0...17,529...7,193,293 13. Amounts receivable relating to uninsured plans, prior year......0...0...0...0...0...0 14. Amounts receivable relating to uninsured plans, current year......0...0...0...0...0...0 15. General expenses paid during year (Lines 10 + 11-12 - 13 + 14)....4,011,897...0...64,742,378...0...155,014...68,909,289 DETAILS OF WRITE-INS 09.301. Sales Promotions......327,684...0...5,092,024...0...0...5,419,708 09.302. Temporary Services......293,630...0...4,947,625...0...0...5,241,255 09.303.......0...0...0...0...0...0 09.398. Summary of remaining write-ins for Line 9.3 from overflow page......0...0...0...0...0...0 09.399. Totals (Lines 09.301 thru 09.303 plus 09.398)(Line 9.3 above)......621,314...0...10,039,649...0...0...10,660,963 (a) Includes management fees of $...0 to affiliates and $...0 to non-affiliates. EXHIBIT 3 - TAXES, LICENSES AND FEES (EXCLUDING FEDERAL INCOME TAXES) Insurance 4 5 1 2 3 Accident All Other Lines Life and Health of Business Investment Total 1. Real estate taxes......0...0...0...31,045...31,045 2. State insurance department licenses and fees......75,916...1,209,450...0...0...1,285,366 3. State taxes on premiums......300,316...4,994,073...0...0...5,294,389 4. Other state taxes, including $...0 for employee benefits......28,724...476,251...0...0...504,975 5. U.S. Social Security taxes......103,527...1,746,729...0...0...1,850,256 6. All other taxes......4,727...76,343...0...0...81,070 7. Taxes, licenses and fees incurred......513,210...8,502,846...0...31,045...9,047,101 8. Taxes, licenses and fees unpaid December 31, prior year......116,127...1,454,015...0...7,664...1,577,806 9. Taxes, licenses and fees unpaid December 31, current year......153,492...2,543,033...0...9,285...2,705,810 10. Taxes, licenses and fees paid during year (Lines 7 + 8-9)......475,845...7,413,828...0...29,424...7,919,097 EXHIBIT 4 - DIVIDENDS OR REFUNDS 1 2 Life Accident and Health 1. Applied to pay renewal premiums......0...0 2. Applied to shorten the endowment or premium-paying period......0...0 3. Applied to provide paid-up additions......0...0 4. Applied to provide paid-up annuities......0...0 5. Total Lines 1 through 4......0...0 6. Paid-in cash......0...0 7. Left on deposit......0...0 8. Aggregate write-ins for dividend or refund options......0...0 9. Total Lines 5 through 8... NONE...0...0 10. Amount due and unpaid......0...0 11. Provision for dividends or refunds payable in the following calendar year......0...0 12. Terminal dividends......0...0 13. Provision for deferred dividend contracts......0...0 14. Amount provisionally held for deferred dividend contracts not included in Line 13......0...0 15. Total Lines 10 through 14......0...0 16. Total from prior year......0...0 17. Total dividends or refunds (Lines 9 + 15-16)......0...0 DETAILS OF WRITE-INS 0801.......0...0 0802.......0...0 0803.......0...0 0898. Summary of remaining write-ins for Line 8 from overflow page......0...0 0899. Totals (Line 0801 thru 0803 plus 0898) (Line 8 above)......0...0 11
Life Insurance: EXHIBIT 5 - AGGREGATE RESERVE FOR LIFE CONTRACTS 1 2 3 4 5 6 Credit (Group and Valuation Standard Total Industrial Ordinary Individual) Group 0100001. 58 CSO (ALB) 3% CRVM......335,448...0...335,448...0...0 0100002. 58 CSO (ALB) 3.5% CRVM......487,938...0...487,938...0...0 0100003. 58 CSO (ANB) 3.5% CRVM......23,229...0...23,229...0...0 0100004. 58 CET (ALB) 3.5% NL......10...0...10...0...0 0100005. 58 CSO (ALB) 4% CRVM......491,095...0...491,095...0...0 0100006. 80 CSO (ALB) 4% CRVM......8,974,601...0...2,003,899...0...6,970,702 0100007. 58 CET (ALB) 4% NL......9,623...0...9,623...0...0 0100008. 80 CSO (ALB) 4.5% CRVM......14,274,295...0...52,176...0...14,222,119 0100009. 80 CSO (ALB) 3% CRVM......0...0...0...0...0 0100010. 80 CSO (ALB) 5.5% CRVM......377,745...0...377,745...0...0 0100011. 2001 CSO-C (ALB) 4% CRVM......2,506,359...0...34,570...0...2,471,789 0100012. Unearned Premium Reserve......14,750...0...12,673...0...2,077 0199997. Totals (Gross)......27,495,093...0...3,828,406...0...23,666,687 0199999. Totals (Net)......27,495,093...0...3,828,406...0...23,666,687 Miscellaneous Reserves: 0700001. Accidental Death Benefit (ADB)......536,716...0...3,222...0...533,494 0700002. Deficiency Reserve......313,080...0...8,036...0...305,044 0700003. Immediate Payment of Claims Reserve......104,582...0...62,544...0...42,038 0700004. Non-Deduction/Refund Reserve......63,323...0...33,310...0...30,013 0700005. Term Life Riders......78,522...0...0...0...78,522 0700006. Waiver of Premium......1,139,427...0...1,768...0...1,137,659 0799997. Totals (Gross)......2,235,650...0...108,880...0...2,126,770 0799999. Totals (Net)......2,235,650...0...108,880...0...2,126,770 9999999. Totals (Net) - Page 3, Line 1......29,730,743...0...3,937,286...0...25,793,457 12
EXHIBIT 5 - INTERROGATORIES 1.1 Has the reporting entity ever issued both participating and non-participating contracts? Yes [ ] No [ X ] 1.2 If not, state which kind is issued 2.1 Does the reporting entity at present issue both participating and non-participating contracts? Yes [ ] No [ X ] 2.2 If not, state which kind is issued 3. Does the reporting entity at present issue or have in force contracts that contain non-guaranteed elements? Yes [ X ] No [ ] If so, attach a statement that contains the determination procedures, answers to the interrogatories and an actuarial opinion as described in the instructions. 4. Has the reporting entity any assessment or stipulated premium contracts in force? If so, state: Yes [ ] No [ X ] 4.1 Amount of insurance: $...0 4.2 Amount of reserve: $...0 4.3 Basis of reserve: 4.4 Basis of regular assessments: 4.5 Basis of special assessments: 4.6 Assessments collected during year: $...0 5. If the contract loan interest rate guaranteed in any one or more of its currently issued contracts is less than 5%, not in advance, state the contract loan rate guarantees on any such contracts. 6. Does the reporting entity hold reserves for any annuity contracts that are less than the reserves that would be held on a standard basis? Yes [ ] No [ X ] 6.1 If so, state the amount of reserve on such contracts on the basis actually held: $...0 6.2 That would have been held (on an exact or approximate basis) using the actual ages of the annuitants; the interest rate(s) used in 6.1; and the same mortality basis used by the reporting entity for the valuation of comparable annuity benefits issued to standard lives. If the reporting entity has no comparable annuity benefits for standard lives to be valued, the mortality basis shall be the table most recently approved by the state of domicile for valuing individual annuity benefits: $...0 Attach statement of methods employed in their valuation. 7. Does the reporting entity have any Synthetic GIC contracts or agreements in effect as of December 31 of the current year? Yes [ ] No [ X ] 7.1 If yes, state the total dollar amount of assets covered by these contracts or agreements: $...0 7.2 Specify the basis (fair value, amortized cost, etc.) for determining the amount: 7.3 State the amount of reserves established for this business: $...0 7.4 Identify where the reserves are reported in the blank. 8. Does the reporting entity have any Contingent Deferred Annuity contracts or agreements in effect as of December of the current year? Yes [ ] No [ X ] 8.1 If yes, state the total dollar amount of account value covered by these contracts or agreements. $...0 8.2 State the amount of reserves established for this business. $...0 8.3 Identify where the reserves are reported in the blank. 9. Does the reporting entity have any Guaranteed Lifetime Income Benefit contracts, agreements or riders in effect as of December 31 of the current year? Yes [ X ] No [ ] 9.1 If yes, state the total dollar amount of any account value associated with these contracts, agreements or riders. $...192,969 9.2 State the amount of reserves established for this business. $...192,969 9.3 Identify where the reserves are reported in the blank. Exhibit 7 EXHIBIT 5A - CHANGES IN BASES OF VALUATION DURING THE YEAR 1 Valuation Basis 4 2 3 Increase in Actuarial Description of Valuation Class Changed From Changed To Reserve Due To Change NONE 13