Experience reported for January 1 to December 31 of 19 | ||||||||||||
To be filed on or before June 30 | ||||||||||||
of the | ||||||||||||
Address (City, State, and Zip Code) | ||||||||||||
NAIC Group Code | NAIC Company Code | CIC Code | ||||||||||
National Experience | ||||||||||||
Form No. | No. of Contracts in Force | Policy Duration | Incurred Losses | Earned Premiums | Loss Ratio | Unearned Premium Reserve | Policy Reserves | Claim Reserves | ||||
Washington Experience | ||||||||||||
Form No. | No. of Contracts in Force | Policy Duration | Incurred Losses | Earned Premiums | Loss Ratio | Unearned Premium Reserve | Policy Reserves | Claim Reserves | ||||
I hereby certify that I have supervised the preparation of this experience exhibit, that it is complete and accurate to the best of my knowledge, and it is in compliance with RCW 48-66-150, and WAC 284-55-115, and WAC 284-55-150. | ||||||||||||
Signature of Officer | Date | |||||||||||
Name and Title of Officer | Prepared by | |||||||||||
Phone Number | ||||||||||||