Form Ci-Drf

PART B - CASE EXPERIENCE: 19___ 19___ 19___ 19___ 1. Actual Earned Premiums 13.18.2 NMAC 12 a. Net Written Premiums* _____ _____ _____ _____ b. Premium Reserve Beginning of Period _____ _____ _____ _____ c. Premium Reserve End of Period _____ _____ _____ _____ d. Earned Premiums (a+b-c) _____ _____ _____ _____ 2. Earned Premiums at Presumptive Rates _____ _____ _____ _____ 3. Incurred Claims a. Claims Paid _____ _____ _____ _____ b. Unreported Claims, Beginning of Period _____ _____ _____ _____ c. Unreported Claims, End of Period _____ _____ _____ _____ d. Claim Reserve, Beginning of Period _____ _____ _____ _____ e. Claim Reserve, End of Period _____ _____ _____ _____ f. Incurred Claims, (a+b+c-d-e) _____ _____ _____ _____ 4. Actual Loss Ratio for Case at Presumptive Rates: 3(f) [divided by] 2 _____ _____ _____ _____ 5. Average Number of Life Years _____ _____ _____ _____ 6. Incurred Claim Count** _____ _____ _____ _____ *Net written premiums are to be determined as Gross Premium written (before deductions for dividends and experience rating credits) less refunds on terminations. **Entries on 5. and 6. should be based on the Credibility Table elected by the insurer.