Untitled Document

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.