Column B

Column C

Column D

Column E

Column F

Column G

Column H

Column I

Column J

Column K

Deferred Policy Acquisition Costs

Reserves for Unpaid Claims and Claim Adjustment Expenses

Discount if any, Deducted In Column C

Unearned Premiums

Earned Premiums

Net Investment Income

Claims and Claim Adjustment Expenses Incurred Related to

Amortization of Deferred Policy Acquisitions Costs

Paid Claims and Claims Adjustment Expenses

Net Premiums Written

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$