Experience Refund Agreement- Exhibit B

Experience Refund Agreement- Exhibit B EXPERIENCE REFUND AGREEMENT 1. Net written premiums _______________________ 2. Premium Reserves - beginning of period _______________________ 3. Premium Reserves - end of period _______________________ 4. Earned premiums [1+2-3] _______________________ 5. Claims paid _______________________ 6. Claims due and unpaid and in course of settlement - _______________________ Beginning of period 7. Claims due and unpaid and in course of settlement - _______________________ End of period 8. Claims incurred but not reported - beginning of period _______________________ 9. Claims incurred but not reported - end of period _______________________ 10. Present value of claims not yet due - beginning of period _______________________ 11. Present value of claims not yet due - end of period _______________________ 12. Incurred claims [5-6+7-8+9-10+11] _______________________ 13. Premium taxes paid _______________________ 14. Premium taxes due and unpaid - beginning of period _______________________ 15. Premium taxes due and unpaid - end of period _______________________ 16. Earned premium taxes [13-14+15] _______________________ 17. Compensation paid or earned during period _______________________ 18. Expenses Incurred _______________________ 19. Experience refund receivable from prior year _______________________ 20. UNDERWRITING PROFIT DUE [4-12-16-17-18-19] _______________________ 21. Percentage due Agent _______________________ 22. EXPERIENCE REFUND DUE [20x11] _______________________