NAIC BLANKS (E) WORKING GROUP
Blanks Agenda Item Submission Form
DATE:
02/08/2012
CONTACT PERSON:
TELEPHONE:
FOR NAIC USE ONLY
Agenda Item # 2012-21BWG
Year
2012
Changes to Existing Reporting
[
]
New Reporting Requirement
[X ]
EMAIL ADDRESS:
REVIEWED FOR ACCOUNTING
PRACTICES AND PROCEDURES IMPACT
ON BEHALF OF:
No Impact [ X ]
Modifies Required Disclosure [
DISPOSITION
NAME:
Michael Consedine & Steve Johnson
TITLE:
AFFILIATION:
Pennsylvania Insurance Department
ADDRESS:
1345 Strawberry Sq.
Harrisburg, PA 17120
[
]
[
]
[ X ]
[
]
[
]
[
]
[
]
]
Rejected For Public Comment
Referred To Another NAIC Group
Received For Public Comment
Adopted Date
Rejected Date
Deferred Date
Other (Specify)
BLANK(S) TO WHICH PROPOSAL APPLIES
[X ]
[X ]
ANNUAL STATEMENT
INSTRUCTIONS
[X ]
[X ]
QUARTERLY STATEMENT
CROSSCHECKS
[ X ] Life and Accident & Health
[
] Separate Accounts
[
] Other Specify
[
[
Property/Casualty
Fraternal
]
]
[X ]
[
[
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BLANK
Health
Title
Anticipated Effective Date: Annual 2012
IDENTIFICATION OF ITEM(S) TO CHANGE
See details on next page.
REASON, JUSTIFICATION FOR AND/OR BENEFIT OF CHANGE**
See details on next page.
NAIC STAFF COMMENTS
Comment on Effective Reporting Date:
Other Comments:
___________________________________________________________________________________________________
** This section must be completed on all forms.
Revised 6/13/2009
© 2012 National Association of Insurance Commissioners
217
IDENTIFICATION OF ITEM(S) TO CHANGE
Add instruction for Certified Reinsurer Identification Number to Schedule S General Instructions
Add line number categories for certified reinsures to Schedule S, Part 3, Section 1 and 2 remaining lines will be renumbered.
Add new Schedule S, Part 5 to the blank and instructions.
Renumber Schedule S, Part 5 to Part 6 and add lines for certified reinsurance to the blank and instructions remaining lines
will be renumbered.
Renumber Schedule S, Part 6 to Part 7 and add lines for certified reinsurance to the blank and instructions remaining lines
will be renumbered.
Add inset to annual and quarterly liability page for certified reinsures for Lines 24.02 and 24.03 also modify the instructions
for those lines.
REASON, JUSTIFICATION FOR AND/OR BENEFIT OF CHANGE**
In 2011, the NAIC adopted revisions to the Credit for Reinsurance Model Law (#785) and Credit for Reinsurance Model
Regulation (#786). These model revisions will act to reduce reinsurance collateral requirements for non-U.S. reinsurers
meeting certain criteria for financial strength and business practices that are domiciled in qualified jurisdictions. Under the
revisions, credit is allowed a domestic ceding insurer for reinsurance ceded to a new class of assuming insurers, certified
reinsurers. As a result, it is necessary to consider revisions to the appropriate reinsurance schedules and instructions in order
to collect the relevant information with respect to these reinsurance transactions.
© 2012 National Association of Insurance Commissioners
218
ANNUAL STATEMENT INSTRUCTIONS – LIFE
SCHEDULE S – REINSURANCE
These parts (except Part 1, which shows reinsurance assumed) provide an analysis by reinsurance carrier of reinsurance
ceded data shown in total in various parts of the statement. Information is included on all reinsurance ceded to other entities
authorized as well as unauthorized or certified in the state of domicile of the reporting entity. Additional data for
unauthorized companies is displayed in Part 4; additional data for certified reinsurers is displayed in Part 5.
Detail Eliminated To Conserve Space
Index to Schedule S
Part 1, Section 1 –
Reinsurance Assumed Life Insurance Annuities, Deposit Funds and Other Liabilities
Without Life or Disability Contingencies, and Related Benefits
Part 1, Section 2 –
Reinsurance Assumed Accident and Health Insurance
–
Reinsurance Recoverable on Paid and Unpaid Losses
Part 2
Part 3, Section 1 –
Reinsurance Ceded Life Insurance, Annuities, Deposit Funds and Other Liabilities Without
Life or Disability Contingencies, and Related Benefits
Part 3, Section 2 –
Reinsurance Ceded Accident and Health Insurance
Part 4
–
Reinsurance Ceded to Unauthorized Companies
Part 5
–
Reinsurance Ceded to Certified Reinsurers
Part 6
–
Five-Year Exhibit of Reinsurance Ceded Business
Part 7
–
Restatement of Balance Sheet to Identify Net Credit for Ceded Reinsurance
Detail Eliminated To Conserve Space
Certified Reinsurer Identification Number
In order to report transactions involving certified reinsurers correctly, the appropriate Certified Reinsurer
Identification Number (CRIN) must be included on Schedule F instead of the FEIN. The CRIN is assigned by the
NAIC and is listed in the NAIC Listing of Companies. If a certified reinsurer does not appear in that publication, an
application for a number should be filed with the NAIC Financial Systems and Services Department, Company
Demographics Analyst. The application must be submitted along with a copy of the license or other document
issued by the company’s domiciliary regulator authorizing it to transact insurance or reinsurance business, and a
copy of the certification issued by the reporting entity’s domiciliary state. Documents submitted in a language other
than English must be accompanied by an English Translation.
Once a number has been assigned, the applying company will be advised so that its Schedule F may be completed or
corrected. Newly assigned numbers are incorporated in revised editions of the NAIC Listing of Companies, which
are available semi-annually. The NAIC also provides this information to annual statement software vendors for
incorporation into the software.
Detail Eliminated To Conserve Space
Determination of Authorized Status
The determination of the authorized, unauthorized or certified status of an insurer or reinsurer listed in any part of
Schedule S shall be based on the status of that insurer or reinsurer in the reporting entity’s state of domicile.
© 2012 National Association of Insurance Commissioners
219
SCHEDULE S  PART 3  SECTION 1
REINSURANCE CEDED LIFE INSURANCE, ANNUITIES, DEPOSIT FUNDS AND OTHER LIABILITIES
WITHOUT LIFE OR DISABILITY CONTINGENCIES, AND RELATED BENEFITS LISTED BY REINSURING
COMPANY AS OF DECEMBER 31, CURRENT YEAR
NOTE:
This schedule is to include Exhibit 7 cessions. Include actual reinsurance ceded on group cases but exclude
jointly underwritten group contracts.
If a reporting entity has any detail lines reported for any of the following required groups, categories, or subcategories, it
shall report the subtotal amount of the corresponding group, category, or subcategory, with the specified subtotal line number
appearing in the same manner and location as the pre-printed total line and number:
Group or Category
Line Number
General Account
Authorized
Affiliates
U.S. Affiliates ....................................................................................................................0199999
Non-U.S. Affiliates ............................................................................................................0299999
Total Authorized Affiliates ................................................................................................ 0399999
Non-Affiliates
U.S. Non-Affiliates ............................................................................................................0499999
Non-U.S. Non-Affiliates ....................................................................................................0599999
Total Authorized Non-Affiliates ........................................................................................0699999
Total General Account Authorized ..................................................................................................0799999
Unauthorized
Affiliates
U.S. Affiliates ....................................................................................................................0899999
Non-U.S. Affiliates ............................................................................................................0999999
Total Unauthorized Affiliates ............................................................................................ 1099999
Non-Affiliates
U.S. Non-Affiliates ............................................................................................................1199999
Non-U.S. Non-Affiliates ....................................................................................................1299999
Total Unauthorized Non-Affiliates ....................................................................................1399999
Total General Account Unauthorized ............................................................................................... 1499999
Certified
Affiliates
U.S. Affiliates ....................................................................................................................1599999
Non-U.S. Affiliates ............................................................................................................1699999
Total Unauthorized Affiliates ............................................................................................ 1799999
Non-Affiliates
U.S. Non-Affiliates ............................................................................................................1899999
Non-U.S. Non-Affiliates ....................................................................................................1999999
Total Unauthorized Non-Affiliates ....................................................................................2099999
Total General Account Certified ....................................................................................................................2199999
Total General Account Authorized, Unauthorized and Certified ...................................................................2299999
© 2012 National Association of Insurance Commissioners
220
Separate Accounts
Authorized
Affiliates
U.S. Affiliates ....................................................................................................................2399999
Non-U.S. Affiliates ............................................................................................................2499999
Total Authorized Affiliates ................................................................................................ 2599999
Non-Affiliates
U.S. Non-Affiliates ............................................................................................................2699999
Non-U.S. Non-Affiliates ....................................................................................................2799999
Total Authorized Non-Affiliates ........................................................................................2899999
Total Separate Accounts Authorized ................................................................................................ 2999999
Unauthorized
Affiliates
U.S. Affiliates ....................................................................................................................3099999
Non-U.S. Affiliates ............................................................................................................3199999
Total Unauthorized Affiliates ............................................................................................ 3299999
Non-Affiliates
U.S. Non-Affiliates ............................................................................................................3399999
Non-U.S. Non-Affiliates ....................................................................................................3499999
Total Unauthorized Non-Affiliates ....................................................................................3599999
Total Separate Accounts Unauthorized ............................................................................................ 3699999
Certified
Affiliates
U.S. Affiliates ....................................................................................................................3799999
Non-U.S. Affiliates ............................................................................................................3899999
Total Unauthorized Affiliates ............................................................................................ 3999999
Non-Affiliates
U.S. Non-Affiliates ............................................................................................................4099999
Non-U.S. Non-Affiliates ....................................................................................................4199999
Total Unauthorized Non-Affiliates ....................................................................................4299999
Total Separate Accounts Certified ..................................................................................................................4399999
Total Separate Accounts Authorized, Unauthorized and Certified.................................................................4499999
Total U.S. (Sum of 0199999, 0499999, 0899999, 1199999, 1599999, 1899999, 2399999, 2699999, 3099999, 3399999,
3799999 and 4099999) ................................................................................................................................................ 4599999
Total Non-U.S. (Sum of 0299999, 0599999, 0999999, 1299999, 1699999, 1999999, 2499999, 2799999, 3199999, 3499999,
3899999 and 4199999) ................................................................................................................................................ 4699999
Total (Sum of 2299999 and 4499999) ......................................................................................................................... 4799999
Detail Eliminated To Conserve Space
© 2012 National Association of Insurance Commissioners
221
SCHEDULE S  PART 3  SECTION 2
REINSURANCE CEDED ACCIDENT AND HEALTH INSURANCE LISTED BY REINSURING COMPANY
AS OF DECEMBER 31, CURRENT YEAR
Include actual reinsurance ceded on group cases but exclude jointly underwritten group contracts.
If a reporting entity has any detail lines reported for any of the following required groups, categories, or subcategories it shall
report the subtotal amount of the corresponding group, category, or subcategory, with the specified subtotal line number
appearing in the same manner and location as the pre-printed total line and number:
Group or Category
Line Number
General Account
Authorized
Affiliates
U.S. Affiliates ....................................................................................................................0199999
Non-U.S. Affiliates ............................................................................................................0299999
Total Authorized Affiliates ................................................................................................ 0399999
Non-Affiliates
U.S. Non-Affiliates ............................................................................................................0499999
Non-U.S. Non-Affiliates ....................................................................................................0599999
Total Authorized Non-Affiliates ........................................................................................0699999
Total General Account Authorized ..................................................................................................0799999
Unauthorized
Affiliates
U.S. Affiliates ....................................................................................................................0899999
Non-U.S. Affiliates ............................................................................................................0999999
Total Unauthorized Affiliates ............................................................................................ 1099999
Non-Affiliates
U.S. Non-Affiliates ............................................................................................................1199999
Non-U.S. Non-Affiliates ....................................................................................................1299999
Total Unauthorized Non-Affiliates ....................................................................................1399999
Total General Account Unauthorized ............................................................................................... 1499999
Certified
Affiliates
U.S. Affiliates ....................................................................................................................1599999
Non-U.S. Affiliates ............................................................................................................1699999
Total Unauthorized Affiliates ............................................................................................ 1799999
Non-Affiliates
U.S. Non-Affiliates ............................................................................................................1899999
Non-U.S. Non-Affiliates ....................................................................................................1999999
Total Unauthorized Non-Affiliates ....................................................................................2099999
Total General Account Certified ....................................................................................................................2199999
Total General Account Authorized, Unauthorized and Certified ...................................................................2299999
© 2012 National Association of Insurance Commissioners
222
Separate Accounts
Authorized
Affiliates
U.S. Affiliates ....................................................................................................................2399999
Non-U.S. Affiliates ............................................................................................................2499999
Total Authorized Affiliates ................................................................................................ 2599999
Non-Affiliates
U.S. Non-Affiliates ............................................................................................................2699999
Non-U.S. Non-Affiliates ....................................................................................................2799999
Total Authorized Non-Affiliates ........................................................................................2899999
Total Separate Accounts Authorized ................................................................................................ 2999999
Unauthorized
Affiliates
U.S. Affiliates ....................................................................................................................3099999
Non-U.S. Affiliates ............................................................................................................3199999
Total Unauthorized Affiliates ............................................................................................ 3299999
Non-Affiliates
U.S. Non-Affiliates ............................................................................................................3399999
Non-U.S. Non-Affiliates ....................................................................................................3499999
Total Unauthorized Non-Affiliates ....................................................................................3599999
Total Separate Accounts Unauthorized ............................................................................................ 3699999
Certified
Affiliates
U.S. Affiliates ....................................................................................................................3799999
Non-U.S. Affiliates ............................................................................................................3899999
Total Unauthorized Affiliates ............................................................................................ 3999999
Non-Affiliates
U.S. Non-Affiliates ............................................................................................................4099999
Non-U.S. Non-Affiliates ....................................................................................................4199999
Total Unauthorized Non-Affiliates ....................................................................................4299999
Total Separate Accounts Certified ..................................................................................................................4399999
Total Separate Accounts Authorized, Unauthorized and Certified.................................................................4499999
Total U.S. (Sum of 0199999, 0499999, 0899999, 1199999, 1599999, 1899999, 2399999, 2699999, 3099999, 3399999,
3799999 and 4099999) ................................................................................................................................................ 4599999
Total Non-U.S. (Sum of 0299999, 0599999, 0999999, 1299999, 1699999, 1999999, 2499999, 2799999, 3199999, 3499999,
3899999 and 4199999) ................................................................................................................................................ 4699999
Total (Sum of 2299999 and 4499999) ......................................................................................................................... 4799999
Detail Eliminated To Conserve Space
© 2012 National Association of Insurance Commissioners
223
SCHEDULE S  PART 5
REINSURANCE CEDED TO CERTIFIED REINSURERS
Contains data on life and accident and health insurance in force that is reinsured with companies that have been certified in
the state of domicile of the reporting insurance company. The purpose of this schedule is to display reinsurance ceded data
used in the development of the liability for reinsurance with certified reinsurers. This liability serves to offset those assets and
liability reductions that reflect the result of reinsurance ceded with certified reinsurers that is not properly collateralized in
accordance with the rating assigned to the certified reinsurer by the commissioner of the reporting company’s state of
domicile.
NOTE: This schedule includes Exhibit 7 cessions.
Securities held on deposit or held in a trust account should be valued at their fair market value. NAIC published market
values must be used when available.
Letters of credit and trust agreements are not to be included in assets or liabilities on Pages 2 or 3 or supporting pages and
exhibits.
If a reporting entity has any detail lines reported for any of the following required groups, categories, or subcategories, it
shall report the subtotal amount of the corresponding group, category, or subcategory, with the specified subtotal line number
appearing in the same manner and location as the pre-printed total line and number:
Group or Category
Line Number
General Account
Life and Annuity
Affiliates
U.S. Affiliates ........................................................................................................................................................ 0199999
Non-U.S. Affiliates ................................................................................................................................................ 0299999
Total Affiliates ....................................................................................................................................................... 0399999
Non-Affiliates
U.S. Non-Affiliates ................................................................................................................................................ 0499999
Non-U.S. Non-Affiliates ........................................................................................................................................ 0599999
Total Non-Affiliates ............................................................................................................................................... 0699999
Total Life and Annuity ............................................................................................................................................................ 0799999
Accident and Health
Affiliates
U.S. Affiliates ........................................................................................................................................................ 0899999
Non-U.S. Affiliates ................................................................................................................................................ 0999999
Total Affiliates ....................................................................................................................................................... 1099999
Non-Affiliates
U.S. Non-Affiliates ................................................................................................................................................ 1199999
Non-U.S. Non-Affiliates ........................................................................................................................................ 1299999
Total Non-Affiliates ............................................................................................................................................... 1399999
Total Accident and Health ....................................................................................................................................................... 1499999
Total General Account .............................................................................................................................................................................. 1599999
Separate Accounts
Affiliates
U.S. Affiliates .......................................................................................................................................................................... 1699999
Non-U.S. Affiliates .................................................................................................................................................................. 1799999
Total Separate Accounts Affiliates .......................................................................................................................................... 1899999
Non-Affiliates
U.S. Non-Affiliates .................................................................................................................................................................. 1999999
Non-U.S. Non-Affiliates .......................................................................................................................................................... 2099999
Total Separate Accounts Non-Affiliates .................................................................................................................................. 2199999
Total Separate Accounts ............................................................................................................................................................................ 2299999
Total U.S. (Sum of 0199999, 0499999, 0899999, 1199999, 1699999 and 1999999) .................................................................................................. 2399999
Total Non-U.S. (Sum of 0299999, 0599999, 0999999, 1299999, 1799999 and 2099999) .......................................................................................... 2499999
Total (Sum of 1599999 and 2299999) ......................................................................................................................................................................... 2599999
© 2012 National Association of Insurance Commissioners
224
Column 6
Certified Reinsurer Rating (1 through 6)
Report the certified reinsurer’s rating as assigned by the reporting company’s domiciliary state.
Column 7
Effective Date of Certified Reinsurer Rating
Report the effective date of the certified reinsurer’s rating that is applicable to the reinsurance
recoverable reported on the individual line. [Note on multiple ratings/downgrades/upgrades/etc?]
Column 8
Percent Collateral Required for Full Credit (0% - 100%)
Report the percentage of collateral that is required to be provided by the certified reinsurer, in
accordance with the rating assigned by the ceding insurer’s domiciliary state in order for a domestic
ceding insurer to receive full financial statement credit for the reinsurance ceded to the certified
reinsurer, that is applicable to the reinsurance recoverable reported on the individual line.
Column 9
–
Reserve Credit Taken
Report the amount by which the aggregate reserve for life contracts (Exhibit 5), deposit-type contracts
(Exhibit 7), and accident and health contracts (Exhibit 6) has been reduced on account of reinsurance
with certified reinsurers. The amounts by company should be the same as those shown for Life
reinsurance ceded in Schedule S, Part 3, Section 1, Column 8 and for accident and health reinsurance
ceded in Schedule S, Part 3, Section 2, Columns 8 and 9.
Column 10
–
Paid and Unpaid Losses Recoverable (Debit)
Report all paid and unpaid losses recoverable, including IBNR.
Include:
Column 11
–
Reduction in claim liability on account of reinsurance on incurred but not
reported claims (estimated).
Other Debits
Report all asset and liability reductions resulting from reinsurance ceded to certified reinsurers not
included in Columns 5 and 6. Examples of items included in this column are:
-
Column 13
–
Unamortized Interest Maintenance Reserve (IMR) liability adjustment, if any, of the ceding
company.
Commissions and expense allowances due the ceding company.
Modified coinsurance reserve adjustments due.
Experience rating refunds due.
Miscellaneous Balances (Credit)
Report amounts due the reinsurer, as a result of day-to-day transaction activity, held by the reporting
insurance company.
Include:
Paid premiums due reinsurers, deferred premiums and any similar amounts that
would be credited as returnable to the reinsurer should the contract terminate as
of the statement date.
© 2012 National Association of Insurance Commissioners
225
Column 14
–
Net Amount Recoverable from Reinsurer
Net Amount Recoverable from Reinsurer (Total Amount Recoverable from Reinsurers minus
Miscellaneous Balances payable to the reinsurer).
Column 15
–
Dollar Amount of Collateral Required
Report the amount of collateral that is required in order for the reporting company to receive full
financial statement credit for reinsurance (Column 14 times Column 8).
Column 16
–
Multiple Beneficiary Trust
If the certified reinsurer utilizes a multiple beneficiary trust account for the purposes of meeting its
collateral requirements as a certified reinsurer to U.S. ceding insurers, report the amounts within such
trust that are applicable to the reporting entity’s reinsurance ceded to the certified reinsurer.
Column 17
–
Letters of Credit
Report the dollar amount of Letters of Credit provided by the certified reinsurer and held by or on
behalf of the reporting entity as security for the certified reinsurer’s reinsurance obligations.
Column 18
–
Letter of Credit Issuing or Confirming Bank American Bankers Association (ABA) Routing Number
Provide the issuing or confirming bank’s nine digit American Bankers Association (ABA) routing
number.
For Fronted Letters of Credit, where a single bank issues a letter of credit as the fronting bank and sells
to other banks undivided interests in its obligations under the credit, list the fronting bank but not the
other banks participating.
For Syndicated Letters of Credit, where one bank acts as agent for a group of banks issuing the letter of
credit but each participating bank is severally, not jointly, liable, leave the column blank. Provide the
ABA routing number for all banks in the syndicate in footnote (a).
For reinsurers providing letters of credit from multiple banks that are not part of a syndicated letter of
credit, leave the column blank. Provide the ABA routing number for all of the banks in footnote (a).
The ABA routing number can be found at the following Web address:
http://abanumberlookup.com/#search
Column 19
–
Letter of Credit Code
Enter “1” for single letter of credit that is not a syndicated letter of credit.
Enter “2” for syndicated letter of credit.
Enter “3” for multiple letters of credit.
Leave blank when no letter of credit exists
© 2012 National Association of Insurance Commissioners
226
Column 20
–
Letter of Credit Issuing or Confirming Bank Name
Provide the name of the issuing or confirming banks whose ABA routing number was provided in
Column 10. The name should be as shown as found on the following Web address:
http://abanumberlookup.com/#search
For Syndicated Letters of Credit, where one bank acts as agent for a group of banks issuing the letter of
credit but each participating bank is severally, not jointly, liable, enter a reference code number in this
column (e.g., 0001, 0002, etc.). Provide the name of each bank in the syndicate in footnote (a).
For reinsurers providing letters of credit from multiple banks that are not part of a syndicated letter of
credit, enter a reference code number in this column (e.g., 0001, 0002, etc.). Provide the name of each
bank in footnote (a).
Column 21
–
Trust Agreements
Report trust funds, other than those held in a multiple beneficiary trust that are reported in Column 16,
Column 22
–
Funds Deposited By and Withheld From Reinsurers
Include:
Where permissible to be taken as credit against the loss and reserve liabilities in
Column 14, amounts deposited by the reinsurer with or for the reporting
insurance company, letters of credit, and trust agreements. Securities held on
deposit or held in a trust fund should be valued at fair market value.
NAIC published market values must be used when available. Letters of credit
and trust agreements are not to be included in assets or liabilities on Pages 2 or 3
or supporting pages and exhibits.
Column 23
–
Other
Report other acceptable security held by or on behalf of the reporting company.
Column 25
Percent of Collateral Provided for Net Amount Recoverable from Reinsurer
Report the percentage of collateral provided by the certified reinsurer for obligations subject to
collateral requirements. (Column 24 divided by Column 14)
Column 26
Percent Credit Allowed on Net Amount Recoverable from Reinsurer
Report the proportion of collateral provided by the certified reinsurer as compared to the amount of
collateral that is required based on its assigned rating. (Column 25 divided by Column 8, not to exceed
100%)
Column 27
Amount of Credit Allowed for Net Amount Recoverable from Reinsurer
Total Provision for Reinsurance with Certified Reinsurers Due to Collateral Deficiency (Column 14
minus (Column 14 times Column 26)
© 2012 National Association of Insurance Commissioners
227
SCHEDULE S  PART 6
FIVE-YEAR EXHIBIT OF REINSURANCE CEDED BUSINESS
A.
Operations Items:
Detail Eliminated To Conserve Space
B.
Balance Sheet Items:
Line 8
–
Premiums and Annuity Considerations for Life and Accident and Health Contracts Deferred and
Uncollected
Exhibit 1, Part 1, Lines 3.3 plus 13.3.
Line 9
–
Aggregate Reserves for Life and Accident and Health Contracts
(+)
(+)
(+)
Exhibit 5, Life Insurance and Annuities, Lines 0199998 and 02999998, Column 2
Exhibit 5, Lines, 0399998, 0499998, 0599998, 0699998 and 0799998, Column 2
Exhibit 6, Line 8, Column 1,
Exhibit 6, Line 15, Column 1.
OR
(+)
(+)
Line 11 –
Schedule S, Part 3 Section 2, Column 8,
Column 9,
Schedule S, Part 3 Section 1, Column 8.
Contract Claims Unpaid
Exhibit 8, Part 1, Line 4.3.
Line 12 –
Amounts Recoverable on Reinsurance
Page 2, Line 16.1, Column 3.
Line 13 –
Experience Rating Refunds Due or Unpaid
Amount included on Page 2, Line 16.3, Column 3.
Line 14 –
Policyholders’ Dividends
Reinsurance ceded portion of Page 3, Lines 5, 6 and 7.
Line 15 –
Commissions and Reinsurance Expense Allowances Unpaid
Amount included on Page 3, Line 11, Column 1.
Line 16 –
Unauthorized Reinsurance Offset
Page 3, Line 24.02 less inset amount.
Line 17 –
Offset for Reinsurance with Certified Reinsurers
Page 3, Line 24.02 inset amount
© 2012 National Association of Insurance Commissioners
228
C.
Unauthorized Reinsurance (Deposits by and Funds Withheld from):
Line 18 –
Funds Deposited by and Withheld From (F)
Schedule S, Part 4, Column 14.
Line 19 –
Letters of Credit (L)
Schedule S, Part 4, Column 9.
Line 20 –
Trust Agreements (T)
Schedule S, Part 4, Column 13.
Line 21 –
Other (O)
Schedule S, Part 4, Column 15.
D.
Reinsurance with Certified Reinsurers (Deposits by and Funds Withheld from):
Line 22 –
Multiple Beneficiary Trusts (M)
Schedule S, Part 5, Column 16
Line 23 –
Funds Deposited by and Withheld From (F)
Schedule S, Part 5, Column 22
Line24 –
Letters of Credit (L)
Schedule S, Part 5, Column 17
Line25 –
Trust Agreements (T)
Schedule S, Part 5, Column 21
Line 26 –
Other (O)
Schedule S, Part 5, Column 23
© 2012 National Association of Insurance Commissioners
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SCHEDULE S  PART 7
RESTATEMENT OF BALANCE SHEET
TO IDENTIFY NET CREDIT FOR CEDED REINSURANCE
Column 1
–
As Reported (Net of Ceded)
Complete data consistent with the data reported for the current year on Page 2, Column 3 and Page 3 of
the annual statement.
Column 2
–
Restatement Adjustments
Enter adjustments to remove the financial statement impact of the ceded reinsurance amounts from
those assets and liabilities in which they are incorporated and to place all of the net balance sheet
impact in a single “Net Credit for Ceded Reinsurance” asset. In most instances, the adjustment will
increase the asset or liability item for the amount of ceded reinsurance that has been deducted from that
item. Two notable exceptions are the reinsurance ceded asset(s), (Page 2, Lines 16.1 through 16.3,
Column 3) and the Liability for Reinsurance in Unauthorized Companies (Page 3, Line 24.02) where
the adjustment moves the item to the (Net Credit for Ceded Reinsurance) asset and zeros out the
original item. Total Capital and Surplus of the company should remain unchanged by the restatement
adjustments.
Column 3
–
Restated (Gross of Ceded)
Sum of Column 1 plus Column 2. Balance sheet restated to show gross assets and liabilities before
netting of ceded reinsurance and total “Net Credit for Ceded Reinsurance.”
Liabilities (Page 3)
Line 16
–
Funds held under reinsurance treaties with unauthorized reinsurers
These amounts should be applied in Column 2 as an offset to the credit taken for ceded reinsurance
recoverable.
Line 18
–
Funds held under reinsurance treaties with certified reinsurers
These amounts should be applied in Column 2 as an offset to the credit taken for ceded reinsurance
recoverable.
Net Credit for Ceded Reinsurance
Column 1
–
As Reported (Net of Ceded)
Analysis of credit for ceded reinsurance, total net (Line 37) to agree with restated asset, Line 4,
Column 3, of this schedule.
© 2012 National Association of Insurance Commissioners
230
LIABILITIES, SURPLUS AND OTHER FUNDS
Detail Eliminated To Conserve Space
Line 24.02
–
Reinsurance in Unauthorized and Certified Companies
Total net amount from Schedule S, Part 4, (Column 8 minus Column 17) plus Schedule S, Part 5,
Column 28.
Line 24.03
–
Funds Held Under Reinsurance Treaties with Unauthorized and Certified Reinsurers
Total amount from Schedule S, Part 4, (Columns 14 and 15) plus Schedule S, Part 5, (Columns 22 and
23), (other than amounts of letters of credit or trust agreements included therein) to the extent that such
funds were included as a part of the total assets on Page 2 of the statement and were not offset by a
directly related credit offset on Page 2.
Detail Eliminated To Conserve Space
© 2012 National Association of Insurance Commissioners
231
ANNUAL STATEMENT BLAK – LIFE
DRAFTING NOTE:
Change the total line numbers on the blank for Schedule S, Part 1, Sections 1 and 2 from 9999999 to 4799999
SCHEDULE S - PART 5
Reinsurance Ceded to Certified Reinsurers as of December 31, Current Year (000 Omitted)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Collateral
Letter of Credit Issuing or
Confirming Bank
18
19
20
25
21
22
23
Percent of
Dollar
Collateral
Percent
Amount
Total
Provided for
Collateral
Total
of
American
Letter of
Funds
Collateral Net Amount
Certified Effective Required
Paid and
Recoverable
Collateral
Bankers
Credit
Deposited
Provided Recoverable
Reinsurer Date of
for Full
Unpaid
from
Net Amount Required
Association Letter Issuing or
by and
(Col. 16
from
Federal
NAIC
Rating (1 Certified
Credit Reserve
Losses
Reinsurer Miscellaneous Recoverable (Col 14
Multiple Letters
(ABA)
of Confirming
Withheld
+ 17 + 21 Reinsurer
ID
Company Effective Name of Domiciliary through Reinsurer
(0% Credit Recoverable Other (Col. 9 + 10
Balances
from
times Col Beneficiary
of
Routing Credit
Bank
Trust
From
+ 22 +
(Col. 24 /
Number
Code
Date
Reinsurer Jurisdiction
6)
Rating
100%)
Taken
(Debit)
Debits
+ 11)
(Credit)
Reinsurer
8)
Trust
Credit
Number
Code
Name
Agreements Reinsurers Other
23)
Col. 14)
2599999
Totals
XXX
XXX
XXX
Detail Eliminated To Conserve Space
© 2012 National Association of Insurance Commissioners
232
26
27
28
24
Percent
Credit
Liability for
Allowed on Amount of Reinsurance
Net Amount
Credit
with
Recoverable Allowed for
Certified
from
Net Amount Reinsurers
Reinsurer Recoverable
Due to
(Col 25 /
from
Collateral
Col 8, not to Reinsurer
Deficiency
exceed
(Col. 14 x
(Col. 14 100%)
Col. 26)
Col. 27)
SCHEDULE S – PART 6
Five-Year Exhibit of Reinsurance Ceded Business
(000 OMITTED)
1
2012
A.
1.
2.
3.
4.
5.
6.
7.
B.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
2
2011
3
2010
4
2009
5
2008
.......................
.......................
.......................
.......................
.......................
.......................
......................
......................
......................
......................
......................
......................
.......................
.......................
.......................
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.......................
.......................
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.......................
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.......................
.......................
.......................
.......................
......................
.......................
.......................
.......................
......................
.......................
.......................
OPERATIONS ITEMS
Premiums and annuity considerations for life and
accident and health contracts .................................................
...........................
Commissions and reinsurance expense allowances ...............
...........................
Contract claims .....................................................................
...........................
Surrender benefits and withdrawals for life contracts ............
...........................
Dividends to policyholders ....................................................
...........................
Reserve adjustments on reinsurance ceded ............................
...........................
Increase in aggregate reserves for life and accident and
health contracts .....................................................................
...........................
BALANCE SHEET ITEMS
Premiums and annuity considerations for life and
accident and health contracts deferred and uncollected .........
...........................
Aggregate reserves for life and accident and
health contracts .....................................................................
...........................
Liability for deposit-type contracts........................................
...........................
Contract claims unpaid ..........................................................
...........................
Amounts recoverable on reinsurance.....................................
...........................
Experience rating refunds due or unpaid ...............................
...........................
Policyholders' dividends (not included in Line 10) ...............
...........................
Commissions and reinsurance expense allowances
...........................
unpaid....................................................................................
...........................
Unauthorized reinsurance offset ............................................
...........................
Offset for reinsurance with Certified Reinsurers
...........................
C.
UNAUTHORIZED REINSURANCE
(DEPOSITS BY AND FUNDS WITHHELD
FROM)
18.
19.
20.
21.
Funds deposited by and withheld from (F) ............................
...........................
Letters of credit (L) ...............................................................
...........................
Trust agreements (T) .............................................................
...........................
Other (O)
...........................
D.
REINSURANCE
WITH
CERTIFIED
REINSURERS (DEPOSITS BY AND FUNDS
WITHHELD FROM)
22.
23.
24
25.
26.
Multiple Beneficiary Trust
Funds deposited by and withheld from (F) ............................
...........................
Letters of credit (L) ...............................................................
...........................
Trust agreements (T) .............................................................
...........................
Other (O)
...........................
© 2012 National Association of Insurance Commissioners
233
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SCHEDULE S – PART 7
Restatement of Balance Sheet to Identify Net Credit for Ceded Reinsurance
1
As Reported
(net of ceded)
ASSETS (Page 2, Col. 3)
Cash and invested assets (Line 12) ...............................................................................
.................................
Reinsurance (Line 16) ...................................................................................................
.................................
Premiums and considerations (Line 15) ........................................................................
.................................
Net credit for ceded reinsurance.................................................................................... XXX
All other admitted assets (balance) ...............................................................................
Total assets excluding Separate Accounts (Line 26) .....................................................
.................................
Separate Account assets (Line 27) ................................................................................
Total assets (Line 28)
LIABILITIES, CAPITAL AND SURPLUS (Page 3)
9. Contract reserves (Lines 1 and 2)..................................................................................
.................................
10. Liability for deposit-type contracts (Line 3)..................................................................
.................................
11. Claim reserves (Line 4) .................................................................................................
.................................
12. Policyholder dividends/reserves (Lines 5 through 7) ....................................................
.................................
13. Premium & annuity considerations received in advance (Line 8) .................................
.................................
14. Other contract liabilities (Line 9) ..................................................................................
.................................
15. Reinsurance in unauthorized companies (Line 24.02)...................................................
.................................
16. Funds held under reinsurance treaties with unauthorized reinsurers
(Line 24.03) ..................................................................................................................
.................................
17. Reinsurance with Certified Reinsurers ..........................................................................
.................................
18. Funds held under reinsurance treaties with Certified Reinsurers ...................................
.................................
19.All other liabilities (balance) ..............................................................................................
20. Total liabilities excluding Separate Accounts (Line 26)................................................
.................................
21. Separate Account liabilities (Line 27) ...........................................................................
22. Total liabilities (Line 28) ..............................................................................................
.................................
23. Capital & surplus (Line 38) ..........................................................................................
24. Total liabilities, capital & surplus (Line 39)
NET CREDIT FOR CEDED REINSURANCE
25. Contract reserves ..........................................................................................................
.................................
26. Claim reserves ..............................................................................................................
.................................
27. Policyholder dividends/reserves ....................................................................................
.................................
28. Premium & annuity considerations received in advance ...............................................
.................................
29. Liability for deposit-type contracts ...............................................................................
.................................
30. Other contract liabilities ................................................................................................
.................................
31. Reinsurance ceded assets ..............................................................................................
.................................
32. Other ceded reinsurance recoverables ...........................................................................
33. Total ceded reinsurance recoverables ............................................................................
34. Premiums and considerations........................................................................................
.................................
35. Reinsurance in unauthorized companies .......................................................................
.................................
36.Funds held under reinsurance treaties with unauthorized reinsurers ...................................
.................................
37. Reinsurance with Certified Reinsurers
.................................
38. Funds held under reinsurance treaties with certified reinsurers
.................................
39. Other ceded reinsurance payables/offsets .....................................................................
40. Total ceded reinsurance payable/offsets ........................................................................
41. Total net credit for ceded reinsurance
1.
2.
3.
4.
5.
6.
7.
8.
© 2012 National Association of Insurance Commissioners
234
2
Restatement
Adjustments
.................................
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3
Restated
(gross of ceded)
..................................
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XXX
ANNUAL AND QUARTERLY STATEMENT BLANK – LIFE
LIABILITIES, SURPLUS AND OTHER FUNDS
1
Current Year
1.Aggregate reserve for life contracts $..................................... (Exhibit 5, Line 9999999) less $ .................. included in Line 6.3 (including
$
Modco Reserve) ................................................................................ .......................................................................................................................
...................
2. Aggregate reserve for accident and health contracts (Exhibit 6, Line 17, Col. 1) (including $........ Modco Reserve) ................................................
...................
3. Liability for deposit-type contracts (Exhibit 7, Line 14, Col. 1) (including $....... Modco Reserve) ............................................................................
...................
4. Contract claims:
4.1 Life (Exhibit 8, Part 1, Line 4.4, Col. 1 less sum of Cols. 9, 10 and 11) ...........................................................................................................
...................
4.2 Accident and health (Exhibit 8, Part 1, Line 4.4, sum of Cols. 9, 10 and 11)....................................................................................................
...................
5. Policyholders' dividends $.................................................. and coupons $............................................... due and unpaid (Exhibit 4, Line 10) .............................
...................
6. Provision for policyholders' dividends and coupons payable in following calendar year—estimated amounts:
6.1 Dividends apportioned for payment (including $ ............... Modco) ................................................................................................................
...................
6.2 Dividends not yet apportioned (including $ ............. Modco)...........................................................................................................................
...................
6.3 Coupons and similar benefits (including $ .............. Modco) ...........................................................................................................................
...................
7. Amount provisionally held for deferred dividend policies not included in Line 6 ......................................................................................................
...................
8. Premiums and annuity considerations for life and accident and health contracts received in advance less $................... discount; including
$............................. accident and health premiums (Exhibit 1, Part 1, Col. 1, sum of Lines 4 and 14)........................................................................
...................
9. Contract liabilities not included elsewhere:
9.1 Surrender values on canceled contracts ............................................................................................................................................................
...................
9.2 Provision for experience rating refunds, including the liability of $.............................................. accident and health experience
rating refunds of which $........................................ is for medical loss ratio rebate per the Public Health Service Act .....................................
...................
9.3 Other amounts payable on reinsurance, including $..................................... assumed and $......................... ceded ...........................................
...................
9.4 Interest Maintenance Reserve (IMR, Line 6) ...................................................................................................................................................
...................
10. Commissions to agents due or accrued-life and annuity contracts $........... accident and health $……. and deposit-type contract funds $ .................
...................
11. Commissions and expense allowances payable on reinsurance assumed ....................................................................................................................
...................
12. General expenses due or accrued (Exhibit 2, Line 12, Col. 6) ....................................................................................................................................
...................
13. Transfers to Separate Accounts due or accrued (net) (including $.............. accrued for expense allowances recognized in reserves, net of
reinsured allowances).................................................................................................................................................................................................
...................
14. Taxes, licenses and fees due or accrued, excluding federal income taxes (Exhibit 3, Line 9, Col. 5) .........................................................................
...................
15.1 Current federal and foreign income taxes, including $....................................… on realized capital gains (losses) .....................................................
...................
15.2 Net deferred tax liability ............................................................................................................................................................................................
...................
16. Unearned investment income .....................................................................................................................................................................................
...................
17. Amounts withheld or retained by company as agent or trustee ...................................................................................................................................
...................
18. Amounts held for agents' account, including $……………. agents' credit balances ...................................................................................................
...................
19. Remittances and items not allocated .........................................................................................................................................................................
...................
20. Net adjustment in assets and liabilities due to foreign exchange rates ........................................................................................................................
...................
21. Liability for benefits for employees and agents if not included above ........................................................................................................................
...................
22. Borrowed money $…………….. and interest thereon $ .............................................................................................................................................
...................
23. Dividends to stockholders declared and unpaid ..........................................................................................................................................................
...................
24. Miscellaneous liabilities:
24.01
Asset valuation reserve (AVR, Line 16, Col. 7) ..........................................................................................................................................
...................
24.02
Reinsurance in unauthorized and certified ($...........) companies .................................................................................................................
...................
24.03
Funds held under reinsurance treaties with unauthorized and certified ($...........) reinsurers .......................................................................
...................
24.04
Payable to parent, subsidiaries and affiliates ...............................................................................................................................................
...................
24.05
Drafts outstanding .......................................................................................................................................................................................
...................
24.06
Liability for amounts held under uninsured plans........................................................................................................................................
...................
24.07
Funds held under coinsurance .....................................................................................................................................................................
...................
24.08
Derivatives .................................................................................................................................................................................................
...................
24.09
Payable for securities ..................................................................................................................................................................................
...................
24.10
Payable for securities lending .....................................................................................................................................................................
...................
24.11
Capital notes $……… and interest thereon $……… ..................................................................................................................................
...................
25. Aggregate write-ins for liabilities ...............................................................................................................................................................................
26. Total liabilities excluding Separate Accounts business (Lines 1 to 25) ......................................................................................................................
27. From Separate Accounts statement ............................................................................................................................................................................
...................
28. Total liabilities (Lines 26 and 27) ..............................................................................................................................................................................
29. Common capital stock................................................................................................................................................................................................
...................
30. Preferred capital stock................................................................................................................................................................................................
...................
31. Aggregate write-ins for other than special surplus funds ............................................................................................................................................
...................
32. Surplus notes .............................................................................................................................................................................................................
...................
33. Gross paid in and contributed surplus (Page 3, Line 33, Col. 2 plus Page 4, Line 51.1, Col. 1) .................................................................................
...................
34. Aggregate write-ins for special surplus funds ............................................................................................................................................................
...................
35. Unassigned funds (surplus) ........................................................................................................................................................................................
...................
36. Less treasury stock, at cost:
36.1 ............ shares common (value included in Line 29 $ ......................) .................................................................................................................
...................
36.2 ............ shares preferred (value included in Line 30 $ ......................) .................................................................................................................
...................
37. Surplus (Total Lines 31 + 32 + 33 + 34 + 35 - 36) (including $............. in Separate Accounts Statement) .................................................................
38. Totals of Lines 29, 30 and 37 (Page 4, Line 55) .........................................................................................................................................................
39. Totals of Lines 28 and 38 (Page 2, Line 28, Col. 3)
Detail Eliminated To Conserve Space
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© 2012 National Association of Insurance Commissioners
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