APPENDIX D

Regulations of Connecticut State Agencies

Sec. APPENDIX D.

Form CR-S – PART 1 – SECTION 1

Reinsurance Assumed Life Insurance, Annuities, Deposit Funds and Other Liabilities Without Life or Disability Contingencies, and Related Benefits Listed by Reinsured Company as of December 31, Current Year

1

Company Code or

ID

Number

2

3

Effective

Date

4

Name

of

Reinsured

5

Location

6

Type of

Reinsurance

Assumed

7

Amount of

In Force at

End of Year

8

Reserve

9

Premiums

10

Reinsurance

Payable on

Paid and

Unpaid

Losses

11

Modified

Coinsurance

Reserve

12

Funds

Withheld

Under

Coinsurance

Totals

Form CR-S – PART 1 – SECTION 2

Reinsurance Assumed Accident and Health Insurance Listed by Reinsured Company as of December 31, Current Year

1

Company

Code or

ID

Number

2

3

Effective

Date

4

Name

of

Reinsured

5

Domiciliary

Jurisdiction

6

Type

of

Reinsurance

Assumed

7

Premiums

8

Unearned

Premiums

9

Reserve

Liability

Other Than

For

Unearned

Premiums

10

Reinsurance

Payable on

Paid and

Unpaid Losses

11

Modified

Coinsurance

Reserve

12

Funds

Withheld

Under

Coinsurance

Totals

Form CR-S – PART 2

Reinsurance Recoverable on Paid and Unpaid Losses Listed by Reinsuring Company as of December 31, Current Year

1

Company

Code or

ID Number

2

3

Effective

Date

4

Name

of

Company

5

Location

6

Paid

Losses

7

Unpaid

Losses

Totals—Life, Annuity and Accident and Health

Form CR-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

1

Company

Code or

ID

Number

2

3

Effective

Date

4

Name

of

Company

5

Location

6

Type of

Reinsurance

Ceded

7

Reserve Credit

Taken

10

Outstanding Surplus Relief

13

Modified

Coinsurance

Reserve

14

Funds

Withheld

Under

Coinsurance

Amount in

Force at

End of Year

8

Current

Year

9

Prior

Year

Premiums

11

Current

Year

12

Prior

Year

Totals

Form CR-S – PART 3 – SECTION 2

Reinsurance Ceded Accident and Health Insurance Listed by Reinsuring Company as of December 31, Current Year

1

Company

Code or

ID

Number

2

3

Effective

Date

4

Name

of

Company

5

Location

6

Type

7

Premiums

8

Unearned

Premiums

(Estimated)

9

Reserve Credit

Taken Other

than for

Unearned Premiums

Outstanding Surplus Relief

12

Modified

Coinsurance

Reserve

13

Funds

Withheld

Under

Coinsurance

10

Current

Year

11

Prior

Year

Totals

(Effective August 6, 2013)