Company Name
Confidential when Completed
NAIC Company Code
SUMMARY FOR AFFILIATED INVESTMENTS
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14)
†
Affiliate Affiliate Type Code Direct U.S. Property and Casualty Subsidiaries 1 Direct U.S. Life Subsidiaries 2 Indirect U.S. Property and Casualty Subsidiaries 3 Indirect U.S. Life Subsidiaries 4 Investment Subsidiaries 5 Holding Company in Excess of Indirect Subsidiaries 6 Alien Life Insurance Subsidiaries: Canadian 7 Alien Insurance Subsidiaries: Non-Canadian Life 8 Investment in Parent 9 Other Affiliate: Property and Casualty Insurers not 10 Subject to Risk-Based Capital Other Affiliate: Life Insurers not Subject to 11 Risk-Based Capital Other Affiliates 12 Publicly Traded Insurance Affiliates 13 Total (Sum of Lines (1) through (13) XXX
(1)
(2)
Statement Value
Book Value † XXX XXX XXX XXX XXX XXX XXX XXX XXX
(3) Difference Col. (1) - (2) XXX XXX XXX XXX XXX XXX XXX XXX XXX
XXX
XXX
X
0.300
=
XXX XXX
XXX XXX
X X X
0.300 0.300 0.225 XXX
= = =
XXX
(4) RBC Basis Subsidiaries' Total Risk-Based Capital After Covariance Subsidiaries' Total Risk-Based Capital After Covariance Subsidiaries' Total Risk-Based Capital After Covariance Subsidiaries' Total Risk-Based Capital After Covariance Subsidiaries' Total Risk-Based Capital After Covariance X 0.300 = Subsidiaries' MCCSR X 1.000 = X 0.300 =
Number of RBC Requirement Companies
If different than statement value. Denotes items that must be manually entered on the filing software.
© 2000 National Association of Insurance Commissioners
LR033
6/30/2000