ACCIDENT AND HEALTH
POLICY EXPERIENCE EXHIBIT
Date of filing: This exhibit is required to be filed not later than June 30
ACCIDENT AND HEALTH POLICY EXPERIENCE EXHIBIT
FOR YEAR 19_____
MADE BY _________________________________________________________________
(Name)
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Incurred Claims and Increase in Policy Reserves |
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Policy Form Numbers |
First Year Issued |
Name of Policy |
Premiums Earned (see note a) |
Amount |
Percent of Premiums Earned |
Commissions Incurred |
Rate of Commissions And Expense Allowance |
Dividends to Policyholders Incurred |
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1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
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A. GROUP AND CERTAIN INDIVIDUAL POLICIES |
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Group . |
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Conversions |
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Premiums $7.50 or less per person annually .. |
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.XXX ... |
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....XXX |
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(List by Policy Form) |
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Sub-Total |
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B. CREDIT (GROUP & INDIVIDUAL) |
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Sub-Total |
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C. HOSPITAL, MEDICAL & SURGICAL POLICIES |
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COLLECTIVELY RENEWABLE |
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1. MASS UNDERWRITING BASIS |
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.. |
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.XXX
... |
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....XXX
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.. |
. |
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.XXX
... |
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....XXX
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.XXX
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....XXX
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2. OTHER |
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.. |
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.XXX
... |
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....XXX
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.. |
. |
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.XXX
... |
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....XXX
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.. |
. |
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.XXX
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....XXX
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Sub-Total |
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.XXX
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....XXX
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NON-CANCELLABLE |
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.. |
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.XXX
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....XXX
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.XXX
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....XXX
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.. |
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.XXX
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....XXX
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Sub-Total |
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.XXX
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....XXX
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GUARANTEED RENEWABLE |
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.. |
. |
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.XXX
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....XXX
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.. |
. |
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.XXX
... |
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....XXX
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.. |
. |
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.XXX
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....XXX
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Sub-Total |
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.XXX
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....XXX
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NON-RENEWABLE FOR STATED REASONS ONLY |
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.. |
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.XXX
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....XXX
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.XXX
... |
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....XXX
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.XXX
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....XXX
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Sub-Total |
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.XXX
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....XXX
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OTHER ACCIDENT ONLY |
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.. |
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.XXX
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....XXX
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.. |
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.XXX
... |
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....XXX
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.. |
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.XXX
... |
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....XXX
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Sub-Total |
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.XXX
... |
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....XXX
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ALL OTHER |
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.. |
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.XXX
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....XXX
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.XXX
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....XXX
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.. |
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.XXX
... |
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....XXX
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Sub-Total |
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.XXX
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....XXX
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D. LOSS OF TIME POLICIES |
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COLLECTIVELY RENEWABLE |
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.. |
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.XXX
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....XXX
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.. |
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.XXX
... |
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....XXX
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.XXX
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....XXX
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Sub-Total |
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.XXX
... |
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....XXX
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NON-CANCELLABLE |
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.. |
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.XXX
... |
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....XXX
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.. |
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.XXX
... |
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....XXX
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.XXX
... |
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....XXX
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Sub-Total |
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.XXX
... |
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....XXX
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GUARANTEED RENEWABLE |
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.. |
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.XXX
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....XXX
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.. |
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.XXX
... |
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....XXX
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.. |
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.XXX
... |
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....XXX
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Sub-Total |
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.XXX
... |
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....XXX
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NON-RENEWABLE FOR STATED REASONS ONLY |
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.. |
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.XXX
... |
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....XXX
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.. |
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.XXX
... |
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....XXX
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.. |
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.XXX
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....XXX
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Sub-Total |
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.XXX
... |
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....XXX
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OTHER ACCIDENT ONLY |
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.. |
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.XXX
... |
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....XXX
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.. |
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.XXX
... |
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....XXX
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.. |
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.XXX
... |
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....XXX
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Sub-Total |
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.XXX
... |
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....XXX
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ALL OTHER |
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.. |
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.XXX
... |
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....XXX
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.. |
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.XXX
... |
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....XXX
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.. |
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.XXX
... |
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....XXX
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Sub-Total |
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.XXX
... |
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....XXX
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E. ALL OTHER POLICIES |
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COLLECTIVLEY RENEWABLE |
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.. |
. |
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.XXX
... |
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....XXX
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.. |
. |
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.XXX
... |
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....XXX
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.. |
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.XXX
... |
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....XXX
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Sub-Total |
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.XXX
... |
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....XXX
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NON-CANCELLABLE |
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.. |
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.XXX
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....XXX
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.. |
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.XXX
... |
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....XXX
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.. |
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.XXX
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....XXX
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Sub-Total |
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.XXX
... |
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....XXX
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GUARANTEED RENEWABLE |
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.. |
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.XXX
... |
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....XXX
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.. |
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.XXX
... |
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....XXX
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.. |
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.XXX
... |
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....XXX
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Sub-Total |
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.XXX
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....XXX
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NON-RENEWABLE FOR STATED REASONS ONLY |
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.. |
. |
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.XXX
... |
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....XXX
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.. |
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.XXX
... |
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....XXX
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.XXX
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....XXX
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Sub-Total |
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.XXX
... |
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....XXX
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OTHER ACCIDENT ONLY |
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.. |
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.XXX
... |
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....XXX
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.. |
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.XXX
... |
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....XXX
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.XXX
... |
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....XXX
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Sub-Total |
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.XXX
... |
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....XXX
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ALL OTHER |
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.. |
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.XXX
... |
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....XXX
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.XXX
... |
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....XXX
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.XXX
... |
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....XXX
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Sub-Total |
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.XXX
... |
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....XXX
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TOTAL DIRECT BUSINESS . |
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REINSURANCE ASSUMED LESS CEDED . |
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TOTALS (to agree with annual statement) |
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Number of Accident and Health Policies in force at End of Year: Group Certificates ________________ Collectively Renewable _______________:
Non-Cancellable ________________: Guaranteed Renewable _______________: Non-Renewable for Stated Reasons Only _______________:
Other Accident Only ________________: All Other _______________:
(a) Premiums earned are before adjustment for the increase in policy reserves which has been treated as a separate deduction.