TABLE 5.2 Plan F COMPANY ABC BENCHMARK/REFUND CALCULATIONS REPORTING YEAR 1994 A) – MEDICARE SUPPLEMENT REFUND CALCULATION FORM FOR CALENDAR YEAR 1994 TYPE: Individual SMSBP(p): Plan F For the State of: State A Company Name: Company ABC NAIC Group Code: 0001 NAIC Co. Code: 0001 Address: 123 Anystreet, Kansas City, MO Person Completing This Exhibit: John Doe Title: Chief Actuary Telephone Number: (123) 456-0000 Experience (b) Current Year’s Earned Premium Incurred Claims Total (all policy years) 7,002,288 2,630,074 Current year’s issues 2,302,520 800,500 c. Net (1a 1b) 4,699,768 1,829,574 – Past Year’s Experience (all policy years) 4,018,540 1,398,247 3. Total Experience (1c + 2) 8,718,308 3,227,821 Refunds Last Year (excluding interest) 38,908 Previous Since Inception (excluding interest) 0 Refunds Since Inception (excluding interest) 38,908 Benchmark Ratio Since Inception (Ratio 1) 0.462 Experienced Since Inception (Ratio 2) 0.372 (Line 3, Col. b)/(Line 3, Col. a Line 6) – Life Years Exposed Since Inception 9,321 If (Line 8 < Line 7) AND (Line 9 > 500), proceed; else stop. Tolerance Permitted (from credibility table) 0.050 Adjustment to Incurred Claims for Credibility 0.422 If Line 11 > Line 7, a refund/credit (Ratio 3 = Ratio 2 + Tolerance) is not required. Adjusted Incurred Claims (Line 3, Col. a Line 6) x Line 11 3,662,707 – Refund (Line 3, Col. a Line 6 (Line 12/Line 7)) – – 751,463 The refund is only paid if it exceeds the Amount De minimus Amount. The distribution De minimus (.005 x Annualized Prem. IF at 12/31) 15,561 methodology must be also. I certify that the above information and calculations are true and accurate to the best of my knowledge and belief. Signature Name (type) Title Date
TABLE 5.2 Plan F COMPANY ABC BENCHMARK/REFUND CALCULATIONS – REPORTING YEAR 1994 A) MEDICARE SUPPLEMENT REFUND CALCULATION FORM FOR CALENDAR YEAR 1994 TYPE: Individual SMSBP(p): Plan F For the State of: State A Company Name: Company ABC NAIC Group Code: 0001 NAIC Co. Code: 0001 Address: 123 Anystreet, Kansas City, MO Person Completing This Exhibit: John Doe Title: Chief Actuary Telephone Number: (123) 456-0000 Current Year’s Experience (b) Earned Premium Incurred Claims Total (all policy years) 7,002,288 2,630,074 Current year’s issues 2,302,520 800,500 c. Net (1a – 1b) 4,699,768 1,829,574 Past Year’s Experience (all policy years) 4,018,540 1,398,247 3. Total Experience (1c + 2) 8,718,308 3,227,821 Refunds Last Year (excluding interest) 38,908 Previous Since Inception (excluding interest) 0 Refunds Since Inception (excluding interest) 38,908 Benchmark Ratio Since Inception (Ratio 1) 0.462 Experienced Since Inception (Ratio 2) 0.372 (Line 3, Col. b)/(Line 3, Col. a – Line 6) Life Years Exposed Since Inception 9,321 If (Line 8 < Line 7) AND (Line 9 > 500), proceed; else stop. Tolerance Permitted (from credibility table) 0.050 Adjustment to Incurred Claims for Credibility 0.422 If Line 11 > Line 7, a refund/credit (Ratio 3 = Ratio 2 + Tolerance) is not required. Adjusted Incurred Claims (Line 3, Col. a – Line 6) x Line 11 3,662,707 Refund (Line 3, Col. a – Line 6 – (Line 12/Line 7)) De minimus Amount (.005 x Annualized Prem. IF at 12/31) 751,463 15,561 The refund is only paid if it exceeds the De minimus Amount. The distribution methodology must be also. I certify that the above information and calculations are true and accurate to the best of my knowledge and belief. Signature Name (type) Title Date
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