MISSOURI DEPARTMENT OF COMMERCE AND INSURANCE
SUPPLEMENT TO PAGE 19 OF
ANNUAL STATEMENT FOR YEAR ENDING
DECEMBER 31, 2019

COMPANY NAME
NAIC GROUP NO.
 
NAIC COMPANY NO.
 
EMAIL
(1)
LINE OF BUSINESS
(2)
DIRECT PREMIUMS WRITTEN
(3)
DIRECT PREMIUMS EARNED
(4)
DIRECT DEFENSE & COST CONTAINMENT EXPENSE INCURRED
(5)
DIRECT LOSSES PAID
(6)
DIRECT LOSSES INCURRED
1. & 2. Fire & Allied Lines
(a) Dwelling
(b) Commercial
(c) Farm
3. Farmowners Multi-Peril
4. (a) Home Owners Multi-Peril
(b) Dwelling Owners Multi-Peril
5. Commercial Multi-Peril
6. Mobile Homes
7. Gowing Crops & Private Crop
8. Ocean Marine
9. Inland Marine (Including Auto Cargo)
10. Financial Guaranty
11. Medical Malpractice Liability
(a) Physicians and Surgeons
(b) Dentists
(c) Nurses
(d) Hospitals
(e) Managed Care Organization errors & omissions
(f) Other
12. Earthquake
14. All Accident & Health (see reverse side)
16. Direct Workers Compensation
17. Other Liability
(a) Bodily Injury & Property Damage
(b) Warranty Programs/Service Contracts
(c) Excess Workers Compensation
18. Product Liability
Bodily Injury & Property Damage
19. (a) (1) Priv. Pass Auto Lia. Bodily Injury
(2) Priv. Pass. Auto Lia. Property Damage
(3) Priv. Pass. Auto Medical Payments
(4) Priv. Pass. Uninsured Motorist
(5) Priv. Pass. Underinsured Motorist
(6) Priv. Pass. Acc. Death & Disability/Dismemberment
(b) (1) Comm. Auto Liability Bodily Injury
(2) Comm. Auto Liability Property Damage
(3) Comm. Auto Medical Payments
(4) Comm. Auto Uninsured/Underinsured Motorist
21. (a) (1) Priv. Pass. Auto Comprehensive
(2) Priv. Pass. Auto Collision
(b) (1) Comm. Auto Comprehensive
(2) Comm. Auto Collisoon
22. Aircraft
23. Fidelity
24. Surety
25. Glass
26. Burglary & Theft
27. Boiler & Machinery
28. (a) Credit Property (excluding V.S.I)
(b) Credit Casualty
(c) Credit Unemployment
(d) Vendor/Lendors Single Interest, Collateral Prot. ect.
29. Mortgage Guaranty
30. Title
31. Professional Liability (excluding a & b)
(a) Lawyers Malpractice
(b) Real Estate Malpractice
32. Umbrella
33. Other Specific (specify)
34. (a) National Flood Insurance Program
(b) Private Flood
35. Federal Crop Insurance Corporation
TOTALS ALL BUSINESS IN MISSOURI 0 0 0 0 0
PLEASE PRINT - COMPANY REPRENSENTATIVE
TELEPHONE NUMBER

INSTRUCTIONS FOR ACCIDENT & HEALTH PORTION OF SUPPLEMENT TO PAGE 19 OF ANNUAL STATEMENT

  1. Number of Insureds as of December 31 of Report Year: For individual policies, the number of insureds must include dependents. For group policies, the number of insureds must equal the number of certificate holders, plus all dependents.
  2. Comprehensive Medical Expense: This category includes major medical, comprehensive medical and other hospital-surgical-medical benefit plans designed to be the insured person's primary health benefit coverage. Do not include plans covering less than 50% of incurred expenses.
  3. Limited Benefit: Includes vision, nursing care (other than long-term care), hospital indemnity and any other single service plan or program, not otherwise reported herein.
  4. Small Employer (2-50 employees) (Line 5.1 a): This term means major medical or comprehensive group medical expense insurance coverage that is subject to the group market provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA).
  5. Association (Line 5. I c): This term means major medical or comprehensive group medical expense insurance coverage sold to members of associations THAT IS NOT subject to the group market provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA).
  6. Small Employer (3-25 employees) (Line 7.1): This term means major medical or comprehensive group medical expense coverage that is subject to The Missouri Small Employer Health Insurance Availability Act.
  7. Stop Loss: Include any premium for employer self-funded group health plan excess loss coverage, including any such coverage issued or provided through minimum premium plans or other self-funded health benefit plans.
  8. Medicare Part D: Pursuant to the Medicare Modernization Act, companies writing prescription drug coverage, through Medicare Part D, must report their data on line numbers 4.13 and/or 5.13.
  9. Medicare Advantage (Lines 4.14 and 5.14): A plan of coverage for health benefits under Medicare Part C as defined in Section 1859 found in Title IV, Subtitle A, Chapter I of PL. 105-33.
  10. Additional association information (lines 8.1 — 8.4): Report only business that offers coverage to associations that include both small (3-25 employees) and large employers. Please refer to the instructions that were included in your packet for additional information.

ACCIDENT & HEALTH INSURANCE

INDIVIDUAL BUSINESS
NUMBER OF INSUREDS DIRECT PREMIUMS WRITTEN DIRECT PREMIUMS EARNED DIVIDENDS PAID OR CREDITED ON DIRECT BUSINESS DIRECT LOSSES PAID DIRECT LOSSES INCURRED
4.1) Comprehensive Medical Expense
(see definition above)
4.2) Medicare Supplement
4.3) Long Term Care
4.4) Specified Disease
4.5) Accident Only
4.6) Disability Income
4.7) Dental
4.8) Limited Benefit
4.9) Short Term Credit Disability
(less than 10 years)
4.10) Long Term Credit Disability (Mortgage)
4.11) Credit Unemployment
4.12) Stop Loss
4.13) Medicare Part D
4.14) Medicare Advantage/Medicare PPO Product
4.15) TOTAL INDIVIDUAL
GROUP BUSINESS
5.1) Comprehensive Medical Expense
a) Small employer (2-50 employees)
b) Large employer/union
(over 50 employees)
c) Association
d) Discretionary
e) Federal Employees (line 23.1)
5.2) Medicare Supplement
5.3) Long Term Care
5.4) Specified Disease
5.5) Accident Only
5.6) Disability Income
5.7) Dental
5.8) Limited Benefit
5.9) Short Term Credit Disability (less than 10 years)
5.10) Long Term Credit Disability
(Mortgage)
5.11) Credit Unemployment
5.12) Stop Loss
5.13) Medicatet Part D
5.14) Medicare Advantage/Medicare PPO Product
5.15) TOTAL GROUP
6) ALL ACCIDENT & HEALTH
7.1) Small employer (3-25) employees
7.2) Number of insured employers reported on Line 5.1a:
7.3) Number of insured employers reported on Line 7.1:
8.1) Small employers (3-25 employees) in associations with rate differentials exceeding 20 percent.
8.2) Small Employers (3-25 employees) in associations with rate differentials NOT exceeding 20%
8.3) Large employers in association plans with rate differentials exceeding 20%
8.4) Large employers in association plans with rate differentials NOT exceeding 20%
8.1a) Number of insured employers reported on Line 8.1:
8.2a) Number of insured employers reported on Line 8.2:
8.3a) Number of insured employers reported on Line 8.3:
8.4a) Number of insured employers reported on Line 8.4:
Explanation if premiums are reported, but no insureds: