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Line | (a) Earned Premium (x) | (b) Incurred Claims (y) |

1. Current Year's Experience a. Total (all policy years) b. Current year's issues (z) c. Net (for reporting purposes = 1a - 1b) | | |

2. Past Years' Experience (All Policy Years) | | |

3. Total experience (Net Current Year + Past Years' Experience) | | |

4. Refunds Last year (Excluding Interest) | | |

5. Previous Since Inception (Excluding Interest) | | |

6. Refunds Since Inception (Excluding Interest) | | |

7. Benchmark Ratio Since Inception (SEE WORKSHEET FOR RATIO 1) | | |

8. Experienced Ratio Since Inception Total Actual Incurred Claims (line 3, col b) Total Earned Premium (line 3, col a) - Refunds Since Inception (line 6) | = Ratio 2 | | |

9. Life Years Exposed Since Inception If the Experienced Ratio is less than the Benchmark Ratio, and there are more than 500 life years exposure, then proceed to calculation of refund. | | |

10. Tolerance Permitted (obtained from credibility table) | | |

11. Adjustment to incurred Claims for Credibility Ratio 3 = Ratio 2 + Tolerance If Ratio 3 is more than benchmark ratio (ratio 1), a refund or credit to premium is not required. If Ratio 3 is less than the benchmark ratio, then proceed. | | |

12. Adjust Incurred Claims = [Total Earned Premium (line 3, col. a) - Refunds Since Inception (line 6)] X Ratio 3 (line 11) | | |

13. Refund = Total Earned Premiums (line 3, col a) - Refunds Since Inception (line 6) - Adjusted Incurred Claims (line 12) Benchmark Ratio (Ratio 1) If the amount on line 13 is less than .005 times the annualized premium in force as of December 31 of the reporting year, then no refund is made. Otherwise, the amount on line 13 is to be refunded or credited, and a description of the refund and/or credit against premiums to be used must be attached to this form. | | |