Appendix E

38a-88-appendixe Sec. 38a-88-appendixe. Appendix E 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 Current Year 9 Prior Year Premiums 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