INVESTMENT EARNINGS/LOSSES FORM


_______________________________________________________________________
(Name of Company)

This form should be completed and furnished with each property and/or casualty rate filing. You may use either total company or line of business data unless otherwise directed by this office. The source of this information is listed on the reverse side of this form. The data on this form was obtained from the company's Annual Statements and Insurance Expense Exhibits for the following calendar years: 19___, 19___ and 19___. Total company data _____ Line of business _____

Unearned Premium    
  (1)

Direct earned premium in Kansas

   
    latest calendar year   $_____
  (2) Mean unearned premiums:    
    A. Direct Kansas unearned premium reserves    
      @12/31 latest calendar year _____  
    B. Direct Kansas unearned premium reserves    
      @12/31 penultimate calendar year _____  
    C. Mean unearned premium 1/2(A + B)   ______
  (3) Deduction for delayed remission of premium:    
    A. Direct country wide earned premium    
      latest calendar year _____  
    B. Direct agents' balances @12/31    
      latest calendar year _____  
    C. Direct agents' balances @12/31    
      penultimate calendar year _____  
    D. Mean agents' balances 1/2(B + C) _____  
    E. Ratio (D) * (A) _____  
    F. Deduction for delayed remission of    
      premium (1) x (E)   ______
  (4) Deduction for prepaid expenses:   ______
    A. Net premium earned _____  
    B. Commission and brokerage _____  
    C. 50% of other acquisition cost _____  
    D. 50% of general expense _____  
    E. Taxes, licenses and fees _____  
    F. Total prepaid expenses    
      (B) + (C) + (D) + (E) _____  
    G. Ratio (F) * (A)   ______
    H. Deduction for prepaid expenses (2C) x (G)   ______
  (5) Net subject to investment (2C) - (3F) - (4H)   ______
Loss reserves:    
  (6) Expected incurred losses    
    (1) x (permissible loss ratio)   ______
  (7) Expected mean loss reserves:    
    A. Direct Kansas loss reserve @12/31    
      latest calendar year _____  
    B. Direct Kansas loss reserve @12/31    
      penultimate calendar year _____  
    C. Mean loss reserve for latest    
      calendar year 1/2(A + B) _____  
    D. Direct Kansas incurred losses for    
      latest calendar year _____  
    E. Ratio (C) * (D) _____  
    F. Direct Kansas loss reserve @12/31    
      penultimate calendar year _____  
    G. Direct Kansas loss reserve @12/31    
      antepenultimate calendar year _____  
    H. Mean loss reserve for penultimate    
      calendar year 1/2(F + G) _____  
    I. Direct Kansas incurred losses for    
      penultimate calendar year _____  
    J. Ratio (H) * (I)   ______
    K. Average 1/2(E + J)   ______
    L. Expected mean loss reserves (6) x (K)   ______
  (8) Expected mean loss and loss adjustment    
    expense reserve:    
    A. Countrywide net loss reserves @12/31    
      latest calendar year _____  
    B. Countrywide net loss reserves @12/31    
      penultimate calendar year _____  
    C. Mean net loss reserve 1/2(A + B) _____  
    D. Countrywide net loss adjustment expense    
      reserve @12/31 latest calendar year _____  
    E. Countrywide net loss adjustment expense reserve    
      @12/31 penultimate calendar year _____  
    F. Mean net loss adjustment expense reserve    
      1/2(D + E)   ______
    G. Ratio 1 + (F * C)   ______
    H. Expected mean loss and loss adjustment    
      expense reserve (7L) x (G)   ______
Total:      
  (9) Total net subject to investment (5) + (8H)   ______
  (10) Pre-tax rate of return:    
    A. Net investment income for latest    
      calendar year _____  
    B. Assets available for investment    
      @12/31 latest calendar year _____  
    C. Assets available for investment    
      @12/31 penultimate calendar year _____  
    D. Mean assets available for    
      investment 1/2(B + C)   ______
    E. Pre-tax rate of return (A) * (D)   ______
  (11) Investment earnings on total net subject to    
    investment (9) x (10E)   ______
  (12) A. Federal income tax on investment    
      earnings _____  
    B. Adjustment to line (a) due to federal    
      income tax changes (specify) _____  
    C. Net federal income tax on investment    
      earnings (A) + or - (B)   ______
  (13) Average rate of return as a percentage of    
    earned premiums ((11) - (12C)) * (1)   ______

Name and telephone number of persons responsible for completion of this form:

____________________________________________________________

Item Source if Based Upon Total Company Data Source if Based Upon Line of Insurance Data
(1) AS:P.14,C.3,L.32 AS:P.14,C.3,Column 1 Line(s)
(2)A AS:P.14,C.5,L.32 AS:P.14,C.3,Column 1 Line(s)
(2)B AS:P.14,C.5,L.32 AS:P.14,C.3,Column 1 Line(s)
(3)A AS:S.T.,C.3,L.98 AS:S.T.,C.3, Line 98
(3)B AS:P.12,L.9.1+L.9.2.,C.1 AS:P.12,L.9.1 + L.9.2.,C.1
(3)C AS:P.12,L.9.1+L.9.2.,C.1 AS:P.12,L.9.1 + L.9.2.,C.1
(4)A IEE:Pt.II,L.2,C.34 IEE:Pt.II,L.2,Line of Business Column
(4)B IEE:Pt.II,L.5,C.34 IEE:Pt.II,L.5,Line of Business Column
(4)C IEE:Pt.II,L.6,C.34 IEE:Pt.II,L.6,Line of Business Column
(4)D IEE:Pt.II,L.7,C.34 IEE:Pt.II,L.7,Line of Business Column
(4)E IEE:Pt.II,L.8,C.34 IEE:Pt.II,L.8,Line of Business Column
(7)A AS:P.14,C.8,L.32 AS:P.14,C.8, Column1 Line(s)
(7)B AS:P.14,C.8,L.32 AS:P.14,C.8, Column1 Line(s)
(7)D AS:P.14,C.7,L.32 AS:P.14,C.7, Column1 Line(s)
(7)F AS:P.14,C.8,L.32 AS:P.14,C.8, Column1 Line(s)
(7)G AS:P.14,C.8,L.32 AS:P.14,C.8, Column1 Line(s)
(7)I AS:P.14,C.7,L.32 AS:P.14,C.7, Column1 Line(s)
(8)A AS:P.10,Pt.3A,C.5,L.32 AS:P.10,Pt.3A,C.5 Line(s) of Business
(8)B AS:P.10,Pt.3A,C.5,L.32 AS:P.10,Pt.3A,C.5 Line(s) of Business
(8)D AS:P.10,Pt.3A,C.6,L.32 AS:P.10,Pt.3A,C.6 Line(s) of Business
(8)E AS:P.10,Pt.3A,C.6,L.32 AS:P.10,Pt.3A,C.6 Line(s) of Business
(10)A AS:P.4,L.9A,C.1 AS:P.4,L.9A,C.1
(10)B AS:P.2,L.8a,C.1 AS:P.2,L.8a,C.1
(10)C AS:P.2,L.8a,C.1 AS:P.2,L.8a,C.1

 

AS = Annual Statement
IEE = Insurance Expense Exhibit
P = Page
C = Column
ST = Schedule "T"
L = Line
Pt = Part

Notes:

(a) The definition for "permissible loss ratio" in Item (6) is: PLR=1 (one) minus Expense Ratio minus Profit and Contingency Ratio.

(b) Data for Item (12) A, B & C should be obtained or calculated from your company's tax records. If done on a line of business basis, your calculations for (12) B must accompany this completed form and must include the adjustments necessary to accommodate current tax treatment of unearned premiums and discounted loss reserves.