23 CAR pt. 25, Appendix D. Form CF-S

Form CR-S – PART 1 – SECTION 1 Reinsurance Assumed Life Insurance, Annuities, Deposit Funds and Other Liabilities Without Life or Disability Contingencies, and Related Benefits Listed by Reinsured Company as of December 31, Current Year 1 Company Code or ID Number 2 3 Effective Date 4 Name of Reinsured 5 Location 6 Type of Reinsurance Assumed 7 Amount of In Force at End of Year 8 Reserve 9 Premiums 10 Reinsurance Payable on Paid and Unpaid Losses 11 Modified Coinsurance Reserve 12 Funds Withheld Under Coinsurance ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........................... ........................... ........................... ........................... ........................... ........................... ........................... ........................... ........................... ........................... ........................... ........................... ........................... ........................... ........................... ........................... ........................... ........................... ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. .............. Totals Form CR-S – PART 1 – SECTION 2 Reinsurance Assumed Accident and Health Insurance Listed by Reinsured Company as of December 31, Current Year 1 Company Code or ID Number 2 3 Effective Date 4 Name of Reinsured 5 Domiciliary Jurisdiction 6 Type of Reinsurance Assumed 7 Premiums 8 Unearned Premiums 9 Reserve Liability Other Than For Unearned Premiums 10 Reinsurance Payable on Paid and Unpaid Losses 11 Modified Coinsurance Reserve 12 Funds Withheld Under Coinsurance ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .............................. .............................. .............................. .............................. .............................. .............................. .............................. .............................. .............................. .............................. .............................. .............................. .............................. .............................. .............................. .............................. .............................. .............................. .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... ............... Totals Form CR-S – PART 2 Reinsurance Recoverable on Paid and Unpaid Losses Listed by Reinsuring Company as of December 31, Current Year 1 Company Code or ID Number 2 3 Effective Date 4 Name of Company 5 Location 6 Paid Losses 7 Unpaid Losses ......... ......... ......... ......... ......... ......... ......... ......... ......... ....... ....... ....... ....... ....... ....... ....... ....... ....... .......... .......... .......... .......... .......... .......... .......... .......... .......... ................................... ................................... ................................... ................................... ................................... ................................... ................................... ................................... ................................... ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................ .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... ......... ......... ......... ......... ......... ......... ......... ......... ......... ....... ....... ....... ....... ....... ....... ....... ....... ....... .......... .......... .......... .......... .......... .......... .......... .......... .......... ................................... ................................... ................................... ................................... ................................... ................................... ................................... ................................... ................................... ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................ ................................ .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... .......................... Totals—Life, Annuity and Accident and Health Form CR-S – PART 3 – SECTION 1 Reinsurance Ceded Life Insurance, Annuities, Deposit Funds and Other Liabilities Without Life or Disability Contingencies, and Related Benefits Listed by Reinsuring Company as of December 31, Current Year 1 Company Code or ID Number 2 3 Effective Date 4 Name of Company 5 Location 6 Type of Reinsurance Ceded 7 Reserve Credit Taken 10 Outstanding Surplus Relief 13 Modified Coinsurance Reserve 14 Funds Withheld Under Coinsurance Amount in Force at End of Year 8 Curren t Year 9 Prior Year Premium s 11 Current Year 12 Prior Year .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ Totals Form CR-S – PART 3 – SECTION 2 Reinsurance Ceded Accident and Health Insurance Listed by Reinsuring Company as of December 31, Current Year 1 Company Code or ID Number 2 3 Effective Date 4 Name of Company 5 Location 6 Type 7 Premiums 8 Unearned Premiums (Estimated) 9 Reserve Credit Taken Other than for Unearned Premiums Outstanding Surplus Relief 12 Modified Coinsurance Reserve 13 Funds Withheld Under Coinsurance 10 Current Year 11 Prior Year .......... .......... .......... .......... .......... .......... .......... .......... .......... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ............................. ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ........ ........ ........ ........ ........ ........ ........ ........ ........ ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. Totals