E Supplement A to Schedule T Reconciliation Form

Section 928.EXHIBIT E   Supplement A to Schedule T Reconciliation Form SCHEDULE T DATA RECONCILIATION FORM Company Name: Line Number Line Loss paid – number of claims Losses paid – dollar amount 1 Schedule T, Supplement A 2 Part 928 claim report totals 3 Difference (line 1 - line 2) Adjustments to Schedule T 4 Sch T – payments reported in current year on claims closed in prior years 5 Sch T – claims not reported in Part 928 claims data for other reasons (claim not reportable in this State, etc.; specify in separate explanation) 6 Correction for other discrepancies (occurrence vs. claims reporting, other accounting issues, etc.; specify in separate explanation) 7 Adjustments to Schedule T (line 1 - line 4 - line 5 - line 6) Adjustments to 928 Claims Data 8 Claims not reported on Schedule T for other reasons (reported for another state, etc.; specify in separate explanation) 9 Other adjustments needed for claims data to reconcile to Schedule T 10 Adjustments to claims data (line 2 - line 8 - line 9) Reconciled Amounts 11 Difference in adjusted amounts (line 7 - line 10) - this line should equal 0. Explanation for adjustments on line 5: Explanation for adjustments on line 6: Explanation for adjustments on line 8: Explanation for adjustments on line 9: