amica mutual insurance company - Rhode Island Department of

Transcription

PROPERTY AND CASUALTY COMPANIES - ASSOCIATION EDITION
QUARTERLY STATEMENT
AS OF MARCH 31, 2006
OF THE CONDITION AND AFFAIRS OF THE
AMICA MUTUAL INSURANCE COMPANY
NAIC Group Code
Organized under the Laws of
0028
0028
(Current)
(Prior)
NAIC Company Code
Rhode Island
19976
Employer's ID Number
, State of Domicile or Port of Entry
Country of Domicile
05-0348344
RI
United States of America
03/01/1907
Incorporated/Organized
Statutory Home Office
Commenced Business
100 Amica Way
(Street and Number)
,
Main Administrative Office
Mail Address
Lincoln , RI 02865-1156
(City or Town, State and Zip Code)
100 Amica Way
(Street and Number)
,
Lincoln , RI 02865-1156
P.O. Box 6008
(Street and Number or P.O. Box)
800-652-6422
(Area Code) (Telephone Number)
,
Primary Location of Books and Records
Providence , RI 02940-6008
100 Amica Way
(Street and Number)
,
Lincoln , RI 02865-1156
Internet Website Address
04/01/1907
800-652-6422
www.amica.com
Statutory Statement Contact
Mary Quinn Williamson
(Name)
[email protected]
(E-mail Address)
Policyowner Relations Contact
,
,
100 Amica Way
(Street and Number)
,
Lincoln , RI 02865-1156
800-652-6422-24665
401-334-2270
(FAX Number)
800-652-6422-24665
OFFICERS
President and Chief
Executive Officer
Vice President and
Secretary
Robert Kenneth MacKenzie
Robert Karl Benson, Sr VP & Chief Investment Officer
Helen Ann Mac Neil, Senior Vice President
Louis Paul Peranzi, Jr., Senior Vice President
Patricia Ann Talin, Senior Vice President
OTHER
Kathleen Fitzpatrick Curran, Vice President
Richard Robert McLaughlin, Jr., Vice President
Paul Alfred Pyne, Senior Vice President
Melvin Stuart Towsey, Jr., Executive Vice President
Stephen Francis Dolan, Vice President
Theodore Charles Murphy, Vice President
Robert Paul Suglia, # Vice President & General Counsel
DIRECTORS OR TRUSTEES
Jeffrey Paul Aiken
Robert Anthony DiMuccio
Michael David Jeans
Donald Julian Reaves
State of
County of
Sr Vice President &
Treasurer
Patricia Walsh Chadwick
Andrew Martin Erickson
Ronald Keith Machtley
Cheryl Watkins Snead
Rhode Island
Providence
Edward Francis DeGraan #
Barry George Hittner
Richard Alan Plotkin
Thomas Alfred Taylor
SS:
The officers of this reporting entity being duly sworn, each depose and say that they are the described officers of said reporting entity, and that on the reporting period stated above,
all of the herein described assets were the absolute property of the said reporting entity, free and clear from any liens or claims thereon, except as herein stated, and that this
statement, together with related exhibits, schedules and explanations therein contained, annexed or referred to, is a full and true statement of all the assets and liabilities and of the
condition and affairs of the said reporting entity as of the reporting period stated above, and of its income and deductions therefrom for the period ended, and have been completed
in accordance with the NAIC Annual Statement Instructions and Accounting Practices and Procedures manual except to the extent that: (1) state law may differ; or, (2) that state
rules or regulations require differences in reporting not related to accounting practices and procedures, according to the best of their information, knowledge and belief,
respectively. Furthermore, the scope of this attestation by the described officers also includes the related corresponding electronic filing with the NAIC, when required, that is an
exact copy (except for formatting differences due to electronic filing) of the enclosed statement. The electronic filing may be requested by various regulators in lieu of or in addition
to the enclosed statement.
President and Chief Executive Officer
Subscribed and sworn to before me this
11th
day of
Lucia M. Bettencourt
Notary Public
06/26/2009
Robert Kenneth MacKenzie
Vice President and Secretary
May, 2006
a. Is this an original filing?
b. If no,
1. State the amendment number
2. Date filed
3. Number of pages attached
Senior Vice President and Treasurer
Yes [ X ] No [
]
STATEMENT AS OF MARCH 31, 2006 OF THE AMICA MUTUAL INSURANCE COMPANY
ASSETS
1.
Bonds
2.
Stocks:
2.1 Preferred stocks
2.2 Common stocks
3.
Mortgage loans on real estate:
3.1 First liens
3.2 Other than first liens
4.
Real estate:
4.1 Properties occupied by the company (less $
encumbrances)
4.2 Properties held for the production of income (less
$
encumbrances)
4.3 Properties held for sale (less $
encumbrances)
5.
Cash ($
), cash equivalents
($
) and short-term
investments ($
)
6.
Contract loans (including $
7.
Other invested assets
premium notes)
8.
Receivables for securities
9.
Aggregate write-ins for invested assets
10.
Subtotals, cash and invested assets (Lines 1 to 9)
11.
Title plants less $
charged off (for Title insurers
only)
12.
Investment income due and accrued
13.
Premiums and considerations:
13.1 Uncollected premiums and agents' balances in the course of collection
13.2 Deferred premiums, agents' balances and installments booked but
deferred and not yet due (including $
earned but unbilled premiums)
13.3 Accrued retrospective premiums
14.
Reinsurance:
14.1 Amounts recoverable from reinsurers
14.2 Funds held by or deposited with reinsured companies
14.3 Other amounts receivable under reinsurance contracts
15.
Amounts receivable relating to uninsured plans
16.1 Current federal and foreign income tax recoverable and interest thereon
16.2 Net deferred tax asset
17.
Guaranty funds receivable or on deposit
18.
Electronic data processing equipment and software
19.
Furniture and equipment, including health care delivery assets
20.
Net adjustment in assets and liabilities due to foreign exchange rates
21.
Receivables from parent, subsidiaries and affiliates
22.
Health care ($
23.
Aggregate write-ins for other than invested assets
24.
Total assets excluding Separate Accounts, Segregated Accounts and
Protected Cell Accounts (Lines 10 to 23)
25.
From Separate Accounts, Segregated Accounts and Protected Cell
Accounts
26.
Total (Lines 24 and 25)
($
)
) and other amounts receivable
DETAILS OF WRITE-INS
0901.
0902.
0903.
0998.
Summary of remaining write-ins for Line 9 from overflow page
0999.
Totals (Lines 0901 through 0903 plus 0998)(Line 9 above)
2301.
2302.
!
"!
!
!
2303.
#$ !
2398.
2399.
!
!
2
1
Current Statement Date
2
Assets
Nonadmitted Assets
3
Net Admitted Assets
(Cols. 1 - 2)
4
December 31
Prior Year Net
Admitted Assets
LIABILITIES, SURPLUS AND OTHER FUNDS
1
Current
Statement Date
1.
Losses (current accident year $
2.
Reinsurance payable on paid losses and loss adjustment expenses
3.
Loss adjustment expenses
4.
Commissions payable, contingent commissions and other similar charges
5.
Other expenses (excluding taxes, licenses and fees)
6.
Taxes, licenses and fees (excluding federal and foreign income taxes)
2
December 31,
Prior Year
)
7.1 Current federal and foreign income taxes (including $
on realized capital gains (losses))
7.2 Net deferred tax liability
8.
Borrowed money $
9.
Unearned premiums (after deducting unearned premiums for ceded reinsurance of $
and interest thereon $
including warranty reserves of $
10.
Advance premium
11.
Dividends declared and unpaid:
and
)
11.1 Stockholders
11.2 Policyholders
12.
Ceded reinsurance premiums payable (net of ceding commissions)
13.
Funds held by company under reinsurance treaties
14.
Amounts withheld or retained by company for account of others
15.
Remittances and items not allocated
16.
Provision for reinsurance
17.
Net adjustments in assets and liabilities due to foreign exchange rates
18.
Drafts outstanding
19.
Payable to parent, subsidiaries and affiliates
20.
Payable for securities
21.
Liability for amounts held under uninsured plans
22.
Capital notes $
23.
Aggregate write-ins for liabilities
24.
Total liabilities excluding protected cell liabilities (Lines 1 through 23)
25.
Protected cell liabilities
26.
Total liabilities (Lines 24 and 25)
27.
Aggregate write-ins for special surplus funds
28.
Common capital stock
29.
Preferred capital stock
30.
Aggregate write-ins for other than special surplus funds
31.
Surplus notes
32.
Gross paid in and contributed surplus
33.
Unassigned funds (surplus)
34.
and interest thereon $
Less treasury stock, at cost:
34.1
shares common (value included in Line 28 $
)
34.2
shares preferred (value included in Line 29 $
)
35.
Surplus as regards policyholders (Lines 27 to 33, less 34)
36.
Totals
2301.
2302.
!
2303.
!#
!
!"
!
# $
2398.
2399.
2701.
'
2702.
*
%
!( )
! (
2703.
2798.
2799.
3001.
3002.
3003.
3098.
3099.
3
&
%
&
STATEMENT OF INCOME
1
Current
Year to Date
UNDERWRITING INCOME
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Premiums earned:
1.1 Direct (written $
1.2 Assumed (written $
1.3 Ceded (written $
1.4 Net (written $
)
)
)
)
DEDUCTIONS:
Losses incurred (current accident year $
2.1 Direct
2.2 Assumed
2.3 Ceded
2.4 Net
Loss expenses incurred
Other underwriting expenses incurred
Aggregate write-ins for underwriting deductions
Total underwriting deductions (Lines 2 through 5)
Net income of protected cells
):
Net underwriting gain or (loss) (Line 1 minus Line 6 + Line 7)
INVESTMENT INCOME
Net investment income earned
Net realized capital gains (losses) less capital gains tax of $
Net investment gain (loss) (Lines 9 + 10)
OTHER INCOME
Net gain or (loss) from agents’ or premium balances charged off (amount recovered
amount charged off $
$
)
Finance and service charges not included in premiums
Aggregate write-ins for miscellaneous income
Total other income (Lines 12 through 14)
19.
20.
Net income before dividends to policyholders, after capital gains tax and before all other federal
and foreign income taxes (Lines 8 + 11 + 15)
Dividends to policyholders
Net income, after dividends to policyholders, after capital gains tax and before all other federal and
foreign income taxes (Line 16 minus Line 17)
Federal and foreign income taxes incurred
Net income (Line 18 minus Line 19)(to Line 22)
21.
CAPITAL AND SURPLUS ACCOUNT
Surplus as regards policyholders, December 31 prior year
17.
18.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
34.
35.
36.
37.
38.
Net income (from Line 20)
Net transfers (to) from Protected Cell accounts
Change in net unrealized capital gains (losses) less capital gains tax of $
Change in net unrealized foreign exchange capital gain (loss)
Change in net deferred income tax
Change in nonadmitted assets
Change in provision for reinsurance
Change in surplus notes
Surplus (contributed to) withdrawn from protected cells
Cumulative effect of changes in accounting principles
Capital changes:
32.1 Paid in
32.2 Transferred from surplus (Stock Dividend)
32.3 Transferred to surplus
Surplus adjustments:
33.1 Paid in
33.2 Transferred to capital (Stock Dividend)
33.3 Transferred from capital
Net remittances from or (to) Home Office
Dividends to stockholders
Change in treasury stock
Aggregate write-ins for gains and losses in surplus
Change in surplus as regards policyholders (Lines 22 through 37)
39.
Surplus as regards policyholders, as of statement date (Lines 21 plus 38)
33.
0501.
0502.
0503.
0598.
0599.
!
1401.
1402.
1403.
1498.
1499.
"
3701.
3702.
3703.
3798.
3799.
!)
.
/
#
'
(
'
%
$ % &'
)
#
''
*
%
! *$
+ $$' *
. ( $
%
$'
#0 *
',
*
-
4
2
Prior Year
to Date
3
Prior Year Ended
December 31
CASH FLOW
Cash from Operations
1.
Premiums collected net of reinsurance
2.
Net investment income
3.
Miscellaneous income
4.
Total (Lines 1 to 3)
5.
Benefit and loss related payments
6.
Net transfers to Separate, Segregated Accounts and Protected Cell Accounts
7.
Commissions, expenses paid and aggregate write-ins for deductions
8.
Dividends paid to policyholders
9.
Federal and foreign income taxes paid (recovered) $
10.
Total (Lines 5 through 9)
11.
Net cash from operations (Line 4 minus Line 10)
12.
Proceeds from investments sold, matured or repaid:
net of tax on capital gains (losses)
Cash from Investments
12.1 Bonds
12.2 Stocks
12.3 Mortgage loans
12.4 Real estate
12.5 Other invested assets
12.6 Net gains or (losses) on cash, cash equivalents and short-term investments
12.7 Miscellaneous proceeds
12.8 Total investment proceeds (Lines 12.1 to 12.7)
13.
Cost of investments acquired (long-term only):
13.1 Bonds
13.2 Stocks
13.3 Mortgage loans
13.4 Real estate
13.5 Other invested assets
13.6 Miscellaneous applications
13.7 Total investments acquired (Lines 13.1 to 13.6)
14.
Net increase (or decrease) in contract loans and premium notes
15.
Net cash from investments (Line 12.8 minus Line 13.7 and Line 14)
Cash from Financing and Miscellaneous Sources
16.
Cash provided (applied):
16.1 Surplus notes, capital notes
16.2 Capital and paid in surplus, less treasury stock
16.3 Borrowed funds
16.4 Net deposits on deposit-type contracts and other insurance liabilities
16.5 Dividends to stockholders
16.6 Other cash provided (applied)
17.
Net cash from financing and miscellaneous sources (Line 16.1 through Line 16.4 minus Line 16.5 plus Line 16.6)
RECONCILIATION OF CASH, CASH EQUIVALENTS AND SHORT-TERM INVESTMENTS
18.
Net change in cash, cash equivalents and short-term investments (Line 11, plus Lines 15 and 17)
19.
Cash, cash equivalents and short-term investments:
19.1 Beginning of year
19.2 End of period (Line 18 plus Line 19.1)
Note: Supplemental disclosures of cash flow information for non-cash transactions:
5
1
Current Year
To Date
2
Prior Year Ended
December 31
NOTES TO FINANCIAL STATEMENTS
Note 1- Summary of Significant Accounting Policies
A.
Accounting Practices
No change.
B.
Use of Estimates in the Preparation of the Financial Statements
No change
C.
Accounting Policies
1-7. No change.
Note 2 – Accounting Changes and Correction of Errors
A.
Accounting Changes and Correction of Errors
No change.
Note 3 – Business Combinations and Goodwill
No change.
Note 4 – Discontinued Operations
No change.
Note 5 – Investments
No change.
Note 6 – Joint Ventures, Partnerships and Limited Liability Companies
No change.
Note 7 – Investment Income
No change.
Note 8 – Derivative Instruments
No change.
Note 9 – Income Taxes
A.
Components of Deferred Tax Assets (DTAs) and Deferred Tax Liabilities (DTLs):
Description
Gross deferred tax assets
Gross deferred tax liabilities
Net deferred tax asset
Non-admitted deferred tax assets
March 31, 2006
$189,989,640
192,965,675
(2,976,035)
0
December 31, 2005
$192,742,772
175,945,476
16,797,296
0
$(2,976,035)
$16,797,296
$0
$0
Admitted deferred tax asset (liability)
Increase (decrease) in non-admitted deferred tax assets
B.
Unrecognized Deferred Tax Liabilities
No change.
C.
Current Tax and Change in Deferred Tax
Current income taxes incurred consist of the following major components:
Description
Federal income tax on operating income
Federal income tax on net capital gains
Federal income tax incurred
March 31, 2006
$21,301,688
5,276,720
$26,578,408
December 31, 2005
$54,558,954
18,271,846
$72,830,800
The tax effects of temporary differences that give rise to significant portions of deferred tax assets and liabilities are as follows:
6
March 31, 2006
December 31, 2005
$82,555,644
17,807,300
45,691,785
25,069,901
5,252,034
8,565,860
5,047,116
$189,989,640
$81,875,726
17,807,300
48,553,241
23,834,653
5,252,034
10,009,213
5,410,606
$192,742,773
$679,918
0
(2,861,456)
1,235,248
0
(1,443,353)
(363,490)
$(2,753,133)
Deferred Tax Liabilities:
Bonds
Common stock
Other invested asset (Hedge fund)
Accrued dividends
Gross deferred tax liabilities
$1,590,731
190,358,348
911,571
105,025
$192,965,675
$1,512,158
173,755,072
543,432
134,815
$175,945,477
$78,573
16,603,276
368,139
(29,790)
$17,020,198
$(2,976,035)
$16,797,296
$(19,773,331)
Net deferred tax asset (liability)
Income Tax Effect of Unrealized Capital Gains
Change in Net Deferred Income Tax
D.
Change
Deferred Tax Assets:
Loss and LAE reserves
Anticipated salvage/subrogation
Unearned premium reserve
Reserve for miscellaneous benefits
Prepaid pension contribution
Furniture, fixtures and equipment
Other
Gross deferred tax assets
16,681,849
($3,091,482)
Reconciliation of Federal Income Tax Rate to Actual Effective Rate
Among the more significant book to tax adjustments were the following:
Income before taxes
Book over tax reserves
Unearned premiums
Excess gain on sale of investments
Retirement benefits
Tax exempt interest
Dividends received deduction
Other than temporary decline in securities value
Other
Taxable income
E.
Amount
$79,813,199
1,942,621
(8,175,589)
(2,389,778)
3,529,281
(2,413,551)
(2,902,610)
1,867,089
4,667,647
$75,938,309
Tax Effect
$27,934,620
679,917
(2,861,456)
(836,422)
1,235,248
(844,743)
(1,015,913)
653,481
1,633,676
$26,578,408
Operating Loss and Tax Credit Carryforwards
No change.
F.
Consolidated Federal Income Tax Return
No change.
Note 10 – Information Concerning Parent, Subsidiaries and Affiliates
On June 16, 2005, Amica Mutual invested $14,500,000 to capitalize a wholly-owned stock insurance subsidiary named Amica Property & Casualty
Insurance Company. It is expected that Amica Property & Casualty Insurance Company will begin issuing policies effective January 1, 2006. We
have received the certificate of authority from Rhode Island and New Jersey, and the certificate of authority is still pending in New York. This
investment is recorded on Amica Mutual’s Schedule D, Part 3, line 6999999.
Note 11 – Debt
No change.
Note 12 –Retirement Plans, Deferred Compensation, Postemployment Benefits and Compensated Absences and Other Postretirement Benefit
Plans
No change.
Note 13 – Capital and Surplus, Shareholders’ Dividend Restrictions and Quasi-Reorganizations
A-H No change.
I.
Changes in Unassigned Funds
The portion of unassigned funds (surplus) represented or reduced by each item below is as follows:
Description
Unrealized gain or (losses)
Non-admitted assets
Separate
business
Provision account
for reinsurance
March 31, 2006
Increase (Decrease)
in Surplus
$32,905,583
5,350,551
0
(222,870)
December 31, 2005
Increase (Decrease)
in Surplus
$41,399,776
17,351,666
0
(1,321,400)
J-L No change.
6.1
Note 14 – Contingencies
No change.
Note 15 – Leases
No change.
Note 16 – Information about Financial Instruments with Off-Balance Sheet Risk and With Concentrations of Credit Risk
No change.
Note 17 – Sale, Transfer and Servicing of Financial Assets and Extinguishment of Liabilities
A-B No change.
C.
No wash sales.
Note 18 – Gain or Loss from Uninsured Accident and Health Plans and the Uninsured Portion of Partially Insured Plans
No change.
Note 19 – Direct Premiums Written / Produced by Managing General Agents / Third Party Administrators
No change.
Note 20 – September 11, 2001 Events
No change.
Note 21 – Other Items
No change.
Note 22 – Events Subsequent
No change.
Note 23 – Reinsurance
No change.
Note 24 – Retrospectively Rated Contracts and Contracts Subject to Redetermination
No change.
Note 25 – Changes in Incurred Losses and Loss Adjustment Expenses
No change.
Note 26 – Intercompany Pooling Arrangements
No change.
Note 27 – Structured Settlements
No change.
Note 28 – Health Care Receivables
No change.
Note 29 – Participating Policies
No change.
Note 30 – Premium Deficiency Reserves
No change.
Note 31 - High Deductibles
No change.
Note 32 – Discounting of Liabilities for Unpaid Losses or Unpaid Loss Adjustment Expenses
No change.
Note 33 – Asbestos and Environmental Reserves
No change.
Note 34 – Subscriber Savings Accounts
No change.
Note 35 – Multiple Peril Crop Insurance
No change.
6.2
GENERAL INTERROGATORIES
(Responses to these interrogatories should be based on changes that have occurred since the prior year end unless otherwise noted)
PART 1 - COMMON INTERROGATORIES
GENERAL
1.1
Did the reporting entity experience any material transactions requiring the filing of Disclosure of Material Transactions with the State of
Domicile, as required by the Model Act?
1.2
If yes, has the report been filed with the domiciliary state?
2.1
Has any change been made during the year of this statement in the charter, by-laws, articles of incorporation, or deed of settlement of the
reporting entity?
2.2
If yes, date of change:
3.
Have there been any substantial changes in the organizational chart since the prior quarter end?
If yes, complete the Schedule Y - Part 1 - organizational chart.
4.1
4.2
Has the reporting entity been a party to a merger or consolidation during the period covered by this statement?
If yes, provide the name of the entity, NAIC Company Code, and state of domicile (use two letter state abbreviation) for any entity that has
ceased to exist as a result of the merger or consolidation.
1
Name of Entity
2
NAIC Company Code
3
State of Domicile
5.
If the reporting entity is subject to a management agreement, including third-party administrator(s), managing general agent(s), attorneyin-fact, or similar agreement, have there been any significant changes regarding the terms of the agreement or principals involved?
If yes, attach an explanation.
6.1
State as of what date the latest financial examination of the reporting entity was made or is being made.
6.2
State the as of date that the latest financial examination report became available from either the state of domicile or the reporting entity. This
date should be the date of the examined balance sheet and not the date the report was completed or released.
6.3
State as of what date the latest financial examination report became available to other states or the public from either the state of domicile or
the reporting entity. This is the release date or completion date of the examination report and not the date of the examination (balance sheet
date).
6.4
By what department or departments?
State of Rhode Island
7.1
Has this reporting entity had any Certificates of Authority, licenses or registrations (including corporate registration, if applicable) suspended or
revoked by any governmental entity during the reporting period?
7.2
If yes, give full information:
8.1
Is the company a subsidiary of a bank holding company regulated by the Federal Reserve Board?
8.2
If response to 8.1 is yes, please identify the name of the bank holding company.
8.3
Is the company affiliated with one or more banks, thrifts or securities firms?
8.4
If response to 8.3 is yes, please provide below the names and location (city and state of the main office) of any affiliates regulated by a federal
regulatory services agency [i.e. the Federal Reserve Board (FRB), the Office of the Comptroller of the Currency (OCC), the Office of Thrift
Supervision (OTS), the Federal Deposit Insurance Corporation (FDIC) and the Securities Exchange Commission (SEC)] and identify the
affiliate'
s primary federal regulator.]
1
Affiliate Name
2
Location (City, State)
7
3
FRB
4
OCC
5
OTS
6
FDIC
7
SEC
FINANCIAL
9.1
Does the reporting entity report any amounts due from parent, subsidiaries or affiliates on Page 2 of this statement?
9.2
If yes, indicate any amounts receivable from parent included in the Page 2 amount:
$
INVESTMENT
10.1
Has there been any change in the reporting entity’s own preferred or common stock?
10.2
If yes, explain:
11.1
Were any of the stocks, bonds, or other assets of the reporting entity loaned, placed under option agreement, or otherwise made available for
use by another person? (Exclude securities under securities lending agreements.)
11.2
If yes, give full and complete information relating thereto:
12.
Amount of real estate and mortgages held in other invested assets in Schedule BA:
$
13.
Amount of real estate and mortgages held in short-term investments:
$
14.1
Does the reporting entity have any investments in parent, subsidiaries and affiliates?
14.2
If yes, please complete the following:
1
Prior Year-End
Book/Adjusted
Carrying Value
2
Current Quarter
Statement Value
14.21 Bonds
$
$
14.22 Preferred Stock
$
$
$
$
$
$
$
$
$
$
$
$
$
14.23 Common Stock
14.24 Short-Term Investments
14.25 Mortgage Loans on Real Estate
14.26 All Other
14.27 Total Investment in Parent, Subsidiaries and Affiliates (Subtotal Lines 14.21 to 14.26)
14.28 Total Investment in Parent included in Lines 14.21 to 14.26 above
$
15.1
Has the reporting entity entered into any hedging transactions reported on Schedule DB?
15.2
If yes, has a comprehensive description of the hedging program been made available to the domiciliary state?
If no, attach a description with this statement.
16.
Excluding items in Schedule E, real estate, mortgage loans and investments held physically in the reporting entity’ s offices, vaults or safety
deposit boxes, were all stocks, bonds and other securities, owned throughout the current year held pursuant to a custodial agreement with a
qualified bank or trust company in accordance with Part 1 - General, Section IV.H - Custodial or Safekeeping Agreements of the NAIC
Financial Condition Examiners Handbook?
16.1
For all agreements that comply with the requirements of the NAIC Financial Condition Examiners Handbook, complete the following:
1
Name of Custodian(s)
2
Custodian Address
! "
16.2
#
* +
& " ()
* +
-
!
3
Complete Explanation(s)
* +
(
$.
Have there been any changes, including name changes, in the custodian(s) identified in 16.1 during the current quarter?
If yes, give full information relating thereto:
2
New Custodian
3
Date of Change
4
Reason
Identify all investment advisors, brokers/dealers or individuals acting on behalf of broker/dealers that have access to the investment accounts,
handle securities and have authority to make investments on behalf of the reporting entity:
1
Central Registration Depository
17.1
17.2
2
Location(s)
,
1
Old Custodian
16.5
'
For all agreements that do not comply with the requirements of the NAIC Financial Condition Examiners Handbook, provide the name,
location and a complete explanation:
1
Name(s)
16.3
16.4
"$% &
2
Name(s)
3
Address
Have all the filing requirements of the Purposes and Procedures Manual of the NAIC Securities Valuation Office been followed?
If no, list exceptions:
7.1
PART 2 - PROPERTY & CASUALTY INTERROGATORIES
1.
If the reporting entity is a member of a pooling arrangement, did the agreement or the reporting entity’s participation change?
2.
Has the reporting entity reinsured any risk with any other reporting entity and agreed to release such entity from liability, in whole or in
part, from any loss that may occur on the risk, or portion thereof, reinsured?
3.1
Have any of the reporting entity’s primary reinsurance contracts been canceled?
3.2
If yes, give full and complete information thereto.
4.1
Are any of the liabilities for unpaid losses and loss adjustment expenses other than certain workers’ compensation tabular reserves
(see Annual Statement Instructions pertaining to disclosure of discounting for definition of “ tabular reserves” ) discounted at a rate of
interest greater than zero?
4.2
If yes, complete the following schedule:
1
Line of Business
2
Maximum
Interest
3
Discount
Rate
4
Unpaid
Losses
TOTAL DISCOUNT
5
6
Unpaid
IBNR
LAE
TOTAL
8
7
TOTAL
8
Unpaid
Losses
DISCOUNT TAKEN DURING PERIOD
9
10
11
Unpaid
IBNR
TOTAL
LAE
SCHEDULE A - VERIFICATION
Real Estate
1
Year to Date
1.
2.
3.
4.
5.
Book/adjusted carrying value, December 31 of prior year
Increase (decrease) by adjustment
Cost of acquired
Cost of additions to and permanent improvements
Total profit (loss) on sales
6.
7.
Increase (decrease) by foreign exchange adjustment
Amount received on sales
8.
9.
10.
11.
12.
2
Prior Year Ended
December 31
Book/adjusted carrying value at end of current period
Total valuation allowance
Subtotal (Lines 8 plus 9)
Total nonadmitted amounts
Statement value, current period (Page 2, real estate lines, Net Admitted Assets column)
SCHEDULE B - VERIFICATION
Mortgage Loans
1
Year to Date
1.
2.
2
Prior Year Ended
December 31
Book value/recorded investment excluding accrued interest on mortgages owned, December 31 of prior year
Amount loaned during period:
2.1. Actual cost at time of acquisitions
NONE
3.
2.2. Additional investment made after acquisitions
Accrual of discount and mortgage interest points and commitment fees
4.
5.
6.
Total profit (loss) on sale
Amounts paid on account or in full during the period
7.
Amortization of premium
8.
9.
10.
11.
Book value/recorded investment excluding accrued interest on mortgages owned at end of current period
12.
13.
Statement value of mortgages owned at end of current period (Page 2, mortgage lines, Net Admitted Assets column)
SCHEDULE BA - VERIFICATION
Other Invested Assets
1
Year to Date
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
2
Prior Year Ended
December 31
Book/adjusted carrying value of long-term invested assets owned, December 31 of prior year
Cost of acquisitions during period:
2.1. Actual cost at time of acquisitions
2.2. Additional investment made after acquisitions
Accrual of discount
Total profit (loss) on sale
Amounts paid on account or in full during the period
Book/adjusted carrying value of long-term invested assets at end of current period
Statement value of long-term invested assets at end of current period (Page 2, Line 7, Column 3)
SCHEDULE D - VERIFICATION
Bonds and Stocks
1
Year to Date
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Book/adjusted carrying value of bonds and stocks, December 31 of prior year
Cost of bonds and stocks acquired
Accrual of discount
Total profit (loss) on disposal
Consideration for bonds and stocks disposed of
Book value/adjusted carrying value, current period
Statement value
9
2
Prior Year Ended
December 31
SCHEDULE D - PART 1B
Showing the Acquisitions, Dispositions and Non-Trading Activity
During the Current Quarter for all Bonds and Preferred Stock by Rating Class
BONDS
1.
Class 1
2.
Class 2
3.
Class 3
4.
Class 4
5.
Class 5
6.
Class 6
7.
Total Bonds
10
PREFERRED STOCK
8.
Class 1
9.
Class 2
10.
Class 3
11.
Class 4
12.
Class 5
13.
Class 6
14.
Total Preferred Stock
15.
Total Bonds and Preferred Stock
1
2
3
4
5
6
7
8
Book/Adjusted
Carrying Value
Beginning
of Current Quarter
Acquisitions
During
Current Quarter
Dispositions
During
Current Quarter
Non-Trading Activity
During
Current Quarter
Book/Adjusted
Carrying Value
End of
First Quarter
Book/Adjusted
Carrying Value
End of
Second Quarter
Book/Adjusted
Carrying Value
End of
Third Quarter
Book/Adjusted
Carrying Value
December 31
Prior Year
SCHEDULE DA - PART 1
Short-Term Investments Owned End of Current Quarter
1
2
3
4
Book/Adjusted
Carrying Value
Par Value
Actual Cost
Interest Collected
Year-to-Date
8299999 Totals
5
Paid for
Accrued Interest
Year-to-Date
XXX
SCHEDULE DA - PART 2 - Verification
Short-Term Investments Owned
1
Year to Date
1.
Book/adjusted carrying value, December 31 of prior year
2.
Cost of short-term investments acquired
3.
4.
5.
Total profit (loss) on disposal of short-term investments
6.
Consideration received on disposal of short-term investments
7.
Book/adjusted carrying value, current period
8.
9.
10.
11.
Statement value (Lines 9 minus 10)
12.
Income collected during period
13.
Income earned during period
11
2
Prior Year Ended
December 31
Schedule DB - Part F - Section 1
NONE
Schedule DB - Part F - Section 2
NONE
Schedule F - Ceded Reinsurance
NONE
12, 13, 14
SCHEDULE T - EXHIBIT OF PREMIUMS WRITTEN
1
Is Insurer
Licensed?
(Yes or
No)
States, etc.
1.
Alabama
AL
2.
Alaska
AK
3.
Arizona
AZ
4.
Arkansas
AR
5.
California
CA
6.
Colorado
CO
7.
Connecticut
CT
8.
Delaware
DE
9.
District of Columbia
DC
10.
Florida
FL
11.
Georgia
GA
12.
Hawaii
HI
13.
Idaho
ID
14.
Illinois
IL
15.
Indiana
IN
16.
Iowa
IA
17.
Kansas
KS
18.
Kentucky
KY
19.
Louisiana
LA
20.
Maine
ME
21.
Maryland
MD
22.
Massachusetts
MA
23.
Michigan
MI
24.
Minnesota
MN
25.
Mississippi
MS
26.
Missouri
MO
27.
Montana
MT
28.
Nebraska
NE
29.
Nevada
NV
30.
New Hampshire
NH
31.
New Jersey
NJ
32.
New Mexico
NM
33.
New York
NY
34.
North Carolina
NC
35.
North Dakota
ND
36.
Ohio
OH
37.
Oklahoma
OK
38.
Oregon
OR
39.
Pennsylvania
PA
40.
Rhode Island
RI
41.
South Carolina
SC
42.
South Dakota
SD
43.
Tennessee
TN
44.
Texas
TX
45.
Utah
UT
46.
Vermont
VT
47.
Virginia
VA
48.
Washington
WA
49.
West Virginia
WV
50.
Wisconsin
WI
51.
Wyoming
WY
52.
American Samoa
AS
53.
Guam
GU
54.
Puerto Rico
PR
55.
U.S. Virgin Islands
VI
56.
Nothern Mariana
Islands
MP
57.
Canada
CN
58.
Aggregate Other Alien OT
59.
Totals
Current Year to Date - Allocated by States and Territories
Direct Premiums Written
2
3
Current Year
To Date
Direct Losses Paid (Deducting Salvage)
4
5
Prior Year
To Date
XXX
(a)
5801.
XXX
5802.
XXX
5803.
XXX
5898. Summary of remaining
write-ins for Line 58 from
overflow page
XXX
5899. Totals (Lines 5801 through
5803 plus 5898)(Line 58
above)
XXX
(a) Insert the number of yes responses except for Canada and Other Alien.
15
Current Year
To Date
Prior Year
To Date
Direct Losses Unpaid
6
7
Current Year
To Date
Prior Year
To Date
SCHEDULE Y – INFORMATION CONCERNING ACTIVITIES OF INSURER MEMBERS OF A HOLDING COMPANY GROUP
PART 1 – ORGANIZATIONAL CHART
AMICA MUTUAL INSURANCE COMPANY
Federal ID Number: 05-0348344
NAIC Company Code – State: 19976 – RI
Parent (Insurer)
100%
AMICA LLOYD’S OF TEXAS, INC.
Attorney-in-fact
NAIC Company Number – State: NONE
Wholly –Owned Subsidiary
Trust
Agreements
Underwriters
100%
100%
100%
AMICA LIFE INSURANCE
COMPANY
AMICA PROPERTY AND
CASUALTY INSURANCE COMPANY
NAIC Company Code – State: 72222 - RI
Wholly-Owned Subsidiary (Insurer)
NAIC Company Code – State: 12287 - RI
Wholly-Owned Subsidiary (Insurer)
16
Management Agreement
AMICA LLOYD’S OF TEXAS
NAIC Company Code – State: 10896 – TX
Affiliated Association (Insurer)
AMICA GENERAL AGENCY, INC.
AMICA GENERAL INSURANCE
AGENCY OF CALIFORNIA, INC.
TOM S. PORTER, INC.
NAIC Company Code – State: NONE
Wholly-Owned Subsidiary
PART 1 - LOSS EXPERIENCE
1.
2.
3.
4.
5.
6.
8.
9.
10.
11.1
11.2
12.
13.
14.
15.
16.
17.1
17.2
18.1
18.2
19.1,19.2
19.3,19.4
21.
22.
23.
24.
26.
27.
28.
29.
30.
31.
32.
33.
34.
3301.
3302.
3303.
3398.
3399.
Lines of Business
Fire
Allied Lines
Farmowners multiple peril
Homeowners multiple peril
Commercial multiple peril
Mortgage guaranty
Ocean marine
Inland marine
Financial guaranty
Medical malpractice - occurrence
Medical malpractice - claims-made
Earthquake
Group accident and health
Credit accident and health
Other accident and health
Workers’ compensation
Other liability - occurrence
Other liability - claims-made
Products liability - occurrence
Products liability - claims-made
Private passenger auto liability
Commercial auto liability
Auto physical damage
Aircraft (all perils)
Fidelity
Surety
Burglary and theft
Boiler and machinery
Credit
International
Reinsurance - Nonproportional Assumed Property
Reinsurance - Nonproportional Assumed Liability
Reinsurance - Nonproportional Assumed Financial Lines
Aggregate write-ins for other lines of business
Totals
1
Direct Premiums
Earned
Current Year to Date
2
Direct Losses
Incurred
3
Direct Loss
Percentage
4
Prior Year to Date
Direct Loss
Percentage
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
Current Quarter
2
Current
Year to Date
3
Prior Year
Year to Date
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
PART 2 - DIRECT PREMIUMS WRITTEN
1
1.
2.
3.
4.
5.
6.
8.
9.
10.
11.1
11.2
12.
13.
14.
15.
16.
17.1
17.2
18.1
18.2
19.1,19.2
19.3,19.4
21.
22.
23.
24.
26.
27.
28.
29.
30.
31.
32.
33.
34.
3301.
3302.
3303.
3398.
3399.
Fire
Allied Lines
Farmowners multiple peril
Homeowners multiple peril
Commercial multiple peril
Mortgage guaranty
Ocean marine
Inland marine
Financial guaranty
Medical malpractice - occurrence
Medical malpractice - claims-made
Earthquake
Group accident and health
Credit accident and health
Other accident and health
Workers’ compensation
Other liability - occurrence
Other liability - claims-made
Products liability - occurrence
Products liability - claims-made
Private passenger auto liability
Commercial auto liability
Auto physical damage
Aircraft (all perils)
Fidelity
Surety
Burglary and theft
Boiler and machinery
Credit
International
Reinsurance - Nonproportional Assumed Property
Reinsurance - Nonproportional Assumed Liability
Reinsurance - Nonproportional Assumed Financial Lines
Aggregate write-ins for other lines of business
Totals
17
PART 3 (000 omitted)
1
Years in Which
Losses
Occurred
1.
2003 + Prior
2.
2004
3.
Subtotals 2004 + Prior
4.
2005
5.
Subtotals 2005 + Prior
6.
2006
7.
Totals
8.
Prior Year-End Surplus
As Regards
Policyholders
2
3
Prior Year-End
Known Case Loss
and LAE Reserves
Prior YearEnd IBNR
Loss and LAE
Reserves
Total Prior
Year-End Loss
and LAE
Reserves
(Cols. 1+2)
XXX
XXX
XXX
LOSS AND LOSS ADJUSTMENT EXPENSE RESERVES SCHEDULE
4
5
2006 Loss and
2006 Loss and
LAE Payments on
LAE Payments on
Claims
Claims Reported
Unreported
as of Prior
as of Prior
Year-End
Year-End
XXX
6
7
8
Total 2006 Loss
and LAE
Payments
(Cols. 4+5)
Q.S. Date Known
Case Loss and
LAE Reserves on
Claims Reported
and Open as of
Prior Year End
Q.S. Date Known
Case Loss and
LAE Reserves on
Claims Reported
or Reopened
Subsequent to
Prior Year End
XXX
9
Q.S. Date IBNR
Loss and LAE
Reserves
10
Total Q.S. Loss
and LAE
Reserves
(Cols.7+8+9)
11
Prior Year-End
Known Case Loss
and LAE Reserves
Developed
(Savings)/
Deficiency
(Cols.4+7
minus Col. 1)
12
Prior Year-End
IBNR Loss and
LAE Reserves
Developed
(Savings)/
Deficiency
(Cols. 5+8+9
minus Col. 2)
Prior Year-End
Total Loss and
LAE Reserve
Developed
(Savings)/
Deficiency
(Cols. 11+12)
XXX
XXX
XXX
Col. 11, Line 7
As % of Col. 1
Line 7
Col. 12, Line 7
As % of Col. 2
Line 7
Col. 13, Line 7
As % of Col. 3
Line 7
1. (9.6)
2. 24.5
13
3. (3.8)
18
Col. 13, Line 7
As a % of Col. 1
Line 8
4. (2.0)
SUPPLEMENTAL EXHIBITS AND SCHEDULES INTERROGATORIES
The following supplemental reports are required to be filed as part of your statement filing. However, in the event that your company does not transact the type of
business for which the special report must be filed, your response of NO to the specific interrogatory will be accepted in lieu of filing a “NONE” report and a bar code will
be printed below. If the supplement is required of your company but is not being filed for whatever reason enter SEE EXPLANATION and provide an explanation following
the interrogatory questions.
Response
1.
Will the Trusteed Surplus Statement be filed with the state of domicile and the NAIC with this statement?
2.
Will Supplement A to Schedule T (Medical Malpractice Supplement) be filed with this statement?
Explanations:
1.
2.
Bar Codes:
1.
Trusteed Surplus Statement [Document Identifier 490]
2.
Supplement A to Schedule T [Document Identifier 450]
19
OVERFLOW PAGE FOR WRITE-INS
Additional Write-ins for Assets Line 23
2304.
2305.
2306.
!
"
2307. $ " %
%
2308.
'
2309.
)*
2310.
'
!
2311. +
! '
2312.
2397. Summary of remaining write-ins for Line 23 from overflow page
#
#
&&
&( (&
#(
(((#
&& #
#
#
&&
&( (&
#(
(((#
&& #
&( &&
Additional Write-ins for Liabilities Line 23
2304.
!
'
2397. Summary of remaining write-ins for Line 23 from overflow page
&
&
20
&
&
Schedule A - Part 2
NONE
Schedule A - Part 3
NONE
Schedule B - Part 1
NONE
Schedule B - Part 2
NONE
E01, E02
SCHEDULE BA - PART 1
1
2
CUSIP
Identification
3
Name or Description
Showing Other Long-Term Invested Assets Acquired During the Current Quarter
Location
5
4
City
6
Name of Vendor
or General Partner
State
7
NAIC
Designation
8
Date
Originally
Acquired
Type
and
Strategy
9
10
Actual
Cost
Amount of
Encumbrances
11
Book/
Adjusted
Carrying
Value Less
Encumbrances
12
13
14
15
16
Fair
Value
Increase
(Decrease)
by
Adjustment
Increase
(Decrease)
by Foreign
Exchange
Adjustment
Commitment
for
Additional
Investment
Percentage of
Ownership
!
!
!
!
"# !$##
"# !$##
3099999. Any Other Class of Assets - Affiliated
3199999. Total - Unaffiliated
3299999. Total - Affiliated
!
!
"!
"!
!
"!
!
!
!
!
!
!
!1 2!2""
!1 2!2""
2 !$ ! 1
2 !$ ! 1
!2##!22
2 !$ ! 1
! #
! #
!1#
!1#
! #
!1#
3399999 - Totals
$!
!
1#! 1$! 1$
! 2! $
1199999. Fixed or Variable Rate - Other Fixed Income - Unaffiliated
XXX
%
% &
'
( ) * + )& ( ) !
'
'
, - .
/ 0
1
2
1799999. Joint Venture Interests - Real Estate - Unaffiliated
40
)5
* . 6
' &
)
. 6
40
)5
* . 6 !
3
1 $ $$"
!" 2
!" 2
! 1$
! 1$
!" 2
! 1$
3
XXX
XXX
XXX
XXX
XXX
E03
SCHEDULE BA - PART 2
1
CUSIP
Identification
2
Name or Description
3
City
Location
Showing Other Long-Term Invested Assets SOLD, Transferred or Paid in Full During the Current Quarter
4
State
5
6
Name of Purchaser or
Nature of Disposal
Date
Originally
Acquired
7
Book/Adjusted
Carrying Value
Less
Encumbrances,
Prior Year
8
Increase
(Decrease) by
Adjustment
9
Increase
(Decrease) by
Foreign
Exchange
Adjustment
NONE
3399999 - Totals
10
Book/Adjusted
Carrying Value
Less
Encumbrances
on Disposal
11
12
13
14
15
Consideration
Received
Foreign
Exchange Gain
(Loss)
on Disposal
Realized Gain
(Loss) on
Disposal
Total Gain
(Loss) on
Disposal
Investment
Income
SCHEDULE D - PART 3
1
2
CUSIP
Identification
Description
Show All Long-Term Bonds and Stock Acquired by the Company During the Current Quarter
3
4
Foreign
Date
Acquired
5
6
Name of Vendor
Number of
Shares of
Stock
7
Actual Cost
8
9
Par Value
Paid for Accrued
Interest and
Dividends
10
NAIC Designation or
Market
Indicator
(a)
0399999. Bonds - U.S. Governments
XXX
Georgia Total
United States Total
1799999. Bonds - States, Territories and Possessions
XXX
XXX
XXX
!
!
"# "
$
%
!
Texas Total
United States Total
2499999. Bonds - Political Subdivisions
&
# '
#
(
""
# $
# "
#
" &
)
XXX
XXX
XXX
#"
# &
# !
&
"
& %
&
#
&
Florida Total
XXX
#
##
&
" )
$
Illinois Total
XXX
# *#
*
&
#
)
#"
& %
Iowa Total
+#
XXX
$
$! &
&
)
## #! &
E04
Kentucky Total
United States Total
3199999. Bonds - Special Revenues
&
&
)
$
+ &
!* ##
& "
#
XXX
XXX
XXX
)
#
# !
$
#
4599999. Bonds - Industrial and Miscellaneous
6099997. Total - Bonds - Part 3
6099999. Total - Bonds
6599997. Total - Preferred Stocks - Part 3
6599999. Total - Preferred Stocks
! )
## !"
#
&
#
%
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
!
#
#
"
6799999. Common Stocks - Banks, Trust and Insurance Companies
XXX
XXX
#
!
(
"
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
& #
$
( !
#"
&
# ##! # %
$
$
")
# &
&
# &
&
")
"" & ! "
)
*&
#
)
$
& # !
!
6899999. Common Stocks - Industrial and Miscellaneous
7299997. Total - Common Stocks - Part 3
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
SCHEDULE D - PART 3
1
2
Show All Long-Term Bonds and Stock Acquired by the Company During the Current Quarter
3
CUSIP
Identification
Description
Foreign
7299999. Total - Common Stocks
7399999. Total - Preferred and Common Stocks
7499999 - Totals
(a) For all common stock bearing the NAIC market indicator "U" provide: the number of such issues
4
Date
Acquired
5
6
Name of Vendor
Number of
Shares of
Stock
7
Actual Cost
8
Par Value
XXX
XXX
XXX
9
Paid for Accrued
Interest and
Dividends
10
NAIC Designation or
Market
Indicator
(a)
XXX
XXX
XXX
E04.1
SCHEDULE D - PART 4
1
2
CUSIP
Identification
Description
3
4
For- Disposal
eign
Date
5
Show All Long-Term Bonds and Stock Sold, Redeemed or Otherwise Disposed of by the Company During the Current Quarter
Name
of Purchaser
6
Number of
Shares of
Stock
7
Consideration
8
Par Value
9
Actual
Cost
10
Prior Year
Book/
Adjusted
Carrying
Value
Change In Book/Adjusted Carrying Value
12
13
14
15
Total
Total
Current Change in Foreign
Book/
Exchange
Year'
s
Current Other Than Adjusted Change in
Book
Unrealized Year'
s Temporary Carrying
/Adjusted
Valuation
(Amor- Impairment Value
(11 + 12 - Carrying
RecogIncrease/ tization)/
13)
Value
(Decrease) Accretion
nized
11
!
!
!
!
!
!
"
!
!
#
!
!
!
!
!
!
!
!
!
!
#
#
$"
E05
#%
&
'
' ('
( $"
&
& (
"
$)
'
'
&
$
$
&
& &'
' $
%#
$
"*
) %
# *
$
$ "
$ +
+
16
Book/
Adjusted
Carrying
Value at
Disposal
Date
17
18
19
20
Bond
Interest/
Foreign
Stock
Exchange Realized
Gain
Gain
Total Gain Dividends
Received
(Loss) on (Loss) on (Loss) on
Disposal Disposal Disposal DuringYear
21
22
Maturity
Date
NAIC
Designation
or
Market
Indicator
(a)
SCHEDULE D - PART 4
1
CUSIP
Identification
!
! "
#
$
$ %
"!
& #
' %(
" %
" $
)
' *
E05.1
) $
* +"
%
"(
&(
( "*
+
"
'
)
)
!+
'
"
! !
!
!
!
! !(
&
)"
' $
*"
) )
$"
#
' %
' )
' !!
' #
&"
$ #
##
+
"
' !
+
#
2
Description
3
4
For- Disposal
eign
Date
5
Name
of Purchaser
6
Number of
Shares of
Stock
7
Consideration
8
Par Value
9
Actual
Cost
10
Prior Year
Book/
Adjusted
Carrying
Value
12
13
14
15
Total
Total
Book/
Exchange
Year'
s
Book
Unrealized Year'
/Adjusted
Valuation
(11 + 12 - Carrying
13)
Value
nized
11
16
Book/
Adjusted
Carrying
Value at
Disposal
Date
17
18
19
20
Bond
Interest/
Foreign
Stock
Exchange Realized
Gain
Gain
Received
21
22
Maturity
Date
NAIC
Designation
or
Market
Indicator
(a)
SCHEDULE D - PART 4
1
2
CUSIP
Identification
3
4
5
For- Disposal
eign
Date
Description
6
Number of
Shares of
Stock
Name
of Purchaser
7
Consideration
8
Par Value
9
Actual
Cost
10
Prior Year
Book/
Adjusted
Carrying
Value
12
13
14
15
Total
Total
Book/
Exchange
Year'
s
Book
Unrealized Year'
/Adjusted
Valuation
(11 + 12 - Carrying
13)
Value
nized
11
16
Book/
Adjusted
Carrying
Value at
Disposal
Date
17
18
19
20
Bond
Interest/
Foreign
Stock
Exchange Realized
Gain
Gain
Received
21
22
Maturity
Date
NAIC
Designation
or
Market
Indicator
(a)
!
"
#
#
'
!
(
#
#
#
#
$
#
E05.2
#
##
#
#
#"
#
$
$
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
%$
%$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$$ #
$$ #
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
&
&
$
$
$
$
$
$
0399999. Bonds - U.S. Governments
"
XXX
%
)
Georgia Total
XXX
% $
$ &
)
#
!
*
$
$
XXX
XXX
XXX
#
&
XXX
$ # * ' + $ *
$ # * ' + $ *
'$
'$
!
!
#
#
XXX
)
%
#
# $
# $ *
) ,
(
%
#
# $
# $ *
) ,
Texas Total
United States Total
2499999. Bonds - Political Subdivisions
*
)'
!
)
* ,
, &
' ,$
XXX
&
&
Kansas Total
&
&
&
&
&
&
&
&
&
&
&
XXX
XXX
XXX
%$
#
Illinois Total
()
%
XXX
&
Louisiana Total
United States Total
1799999. Bonds - States, Territories and Possessions
#
XXX
&
$
$
'
+
)
'
+
)
XXX
&
&
XXX
XXX
XXX
XXX
XXX
XXX
SCHEDULE D - PART 4
1
2
CUSIP
Identification
3
4
For- Disposal
eign
Date
Description
5
Name
of Purchaser
6
Number of
Shares of
Stock
7
Consideration
8
Par Value
9
Actual
Cost
10
Prior Year
Book/
Adjusted
Carrying
Value
12
13
14
15
Total
Total
Book/
Exchange
Year'
s
Book
Unrealized Year'
/Adjusted
Valuation
(11 + 12 - Carrying
13)
Value
nized
11
16
Book/
Adjusted
Carrying
Value at
Disposal
Date
17
18
19
20
Bond
Interest/
Foreign
Stock
Exchange Realized
Gain
Gain
Received
21
22
Maturity
Date
NAIC
Designation
or
Market
Indicator
(a)
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
!
"
"
" #
$
$
%
&
&
&
&
&
&
' !&
" !
)
(
&
'"
(
(
*
E05.3
""
""
""
""
""
""
""
""
""
""
""
""
""
""
""
""
""
%
%
%
% )
+
* +
*)
% +
%
%
") "
*)
$
+
%
% $
% &
&
*
& $
'
) +
!
'
&
&
&
&
&
&
"
"
&
&
&
&
*
*
*
*
*
*
*
*
*
*
*
&
&
&
&
&
&
&
&
&
&
&
" & &
&& &&
#
&
&
&
&
"
%
&
&
&
&
&
&
&
&
&
&
&
"
$
+$
("
$
"
&
%
& *
*
"
"
Mississippi Total
(
*
! % &
"
New Mexico Total
)
*!
%
%
%&*
%&*
* )
* )
&
&
$
"
"
Ohio Total
%
%&*
*)
&
$
"
Oklahoma Total
* + &
Texas Total
&
"
SCHEDULE D - PART 4
1
2
3
CUSIP
Identification
Description
United States Total
3199999. Bonds - Special Revenues
!
#
#
"
#
" #
4
5
For- Disposal
eign
Date
"
6
Name
of Purchaser
7
Number of
Shares of
Stock
" $
" $
%
"
E05.4
#
%
$
&
#
" #
'
" #
#$
"
$
& (
& " !$
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
'
'
'
" #
*
Maturity
Date
XXX
XXX
NAIC
Designation
or
Market
Indicator
(a)
XXX
XXX
'
'
'
$
$
"
$
22
#
!
$
%
Bond
Interest/
Foreign
Stock
Exchange Realized
Gain
Gain
Received
21
#
%
%
$
20
'
#
*
19
'
'
'
"
% & !$
"
#
18
'
'
'
'
'
'
$
" )
"
"
" #
Book/
Adjusted
Carrying
Value at
Disposal
Date
17
'
!
) &
16
&
&
6799999. Common Stocks - Banks, Trust and Insurance Companies
#
Prior Year
Book/
Adjusted
Carrying
Value
12
13
14
15
Total
Total
Book/
Exchange
Year'
s
Book
Unrealized Year'
/Adjusted
Valuation
(11 + 12 - Carrying
13)
Value
nized
11
!
!
!
!
!
4599999. Bonds - Industrial and Miscellaneous
6099999. Total - Bonds
6599999. Total - Preferred Stocks
$
$
Actual
Cost
10
%
"
$ $"
Par Value
9
" $
# $""
&
Consideration
8
!$
#
"
" #
"
!
'
'
'
'
6899999. Common Stocks - Industrial and Miscellaneous
7299999. Total - Common Stocks
7399999. Total - Preferred and Common Stocks
7499999 - Totals
(a) For all common stock bearing the NAIC market indicator "U" provide: the number of such issues
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
Schedule DB - Part A - Section 1
NONE
Schedule DB - Part B - Section 1
NONE
Schedule DB - Part C - Section 1
NONE
Schedule DB - Part D - Section 1
NONE
E06, E07
SCHEDULE E - PART 1 - CASH
1
2
#$%
4
5
Book Balance at End of Each Month
During Current Quarter
6
7
8
First Month
#%
0199998. Deposits in ...
49 depositories that do
not exceed the allowable limit in any one depository (See
instructions) - Open Depositories
0199999. Totals - Open Depositories
0299998. Deposits in ...
depositories that do not
exceed the allowable limit in any one depository (See
instructions) - Suspended Depositories
0299999. Totals - Suspended Depositories
0399999. Total Cash on Deposit
0499999. Cash in Company'
s Office
0599999. Total - Cash
3
Amount of
Amount of
Interest Received Interest Accrued
Rate of During Current
at Current
Code Interest
Quarter
Statement Date
Depository
!"
Month End Depository Balances
Second Month
9
Third Month
*
&
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
&
&
XXX
XXX
&
E08
&&
&
&
&&
&&
&
&
&&
&&
&&
XXX
XXX
&&
&&
XXX
XXX
XXX
XXX
&&
XXX
SCHEDULE E - PART 2 - CASH EQUIVALENTS
1
2
CUSIP Identification
Description
Show Investments Owned End of Current Quarter
3
4
5
6
Code
Date Acquired
Rate of Interest
Maturity Date
E09
NONE
0199999 - Total Cash Equivalents
7
Book/Adjusted
Carrying Value
8
Amount of Interest
Due and Accrued
9
Gross Investment
Income

amica mutual insurance company - Rhode Island Department of

Transcription

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