APPENDIX C

Regulations of Connecticut State Agencies

Sec. APPENDIX C.

Form CR-F – PART 1

Assumed Reinsurance as of December 31, Current Year (000 Omitted)

1

2

3

4

5

Reinsurance On

9

10

11

12

13

14

15

Company

Code or

ID

Number

Name of

Reinsured

Domiciliary

Jurisdiction

Assumed

Premium

6

Paid Losses and

Loss

Adjustment

Expenses

7

Known Case

Losses and LAE

8

Cols. 6 + 7

Contingent

Commissions

Payable

Assumed

Premiums

Receivable

Unearned

Premium

Funds Held

By or

Deposited

With

Reinsured

Companies

Letters

of

Credit Posted

Amount of

Assets

Pledged or

Compensating

Balances to

Secure Letters

of Credit

Amount of

Assets

Pledged or

Collateral

Held in Trust

9999999 Totals

Form CR-F – PART 2

Ceded Reinsurance as of December 31, Current Year (000 Omitted)

1

2

3

4

5

6

Reinsurance Recoverable On

Reinsurance Payable

18

19

Company

Code or

ID

Number

Name

of

Reinsurer

Domiciliary

Jurisdiction

Reinsurance

Contracts

Ceding 75%

or More of

Direct

Premiums

Written

Reinsurance

Premiums

Ceded

7

Paid

Losses

8

Paid

LAE

9

Known

Case Loss

Reserves

10

Known

Case LAE

Reserves

11

IBNR

Loss

Reserves

12

IBNR

LAE

Reserves

13

Unearned

Premiums

14

Contingent

Commissions

15

Cols. 7 through 14 Totals

16

Ceded

Balances

Payable

17

Other

Amounts

Due to

Reinsurers

Net Amount

Recoverable

From

Reinsurers

Cols. 15 –

Funds Held

by

Company

Under

Reinsurance

Treaties

9999999 Totals

(Effective August 6, 2013)