Screen A-2 - Insurance Carrier General Information (5500)

Experience-Rated Contracts

Premiums: Increase / decrease in amount due but unpaid
Enter the increase or decrease in the amount of premiums that are due but have not been paid between the prior and current years. Enter a negative number to indicate a decrease in the amount.
Premiums: Increase / decrease in unearned premium reserve
Enter the increase or decrease in the amount of unearned premium reserve between the prior and current years. Enter a negative number to indicate a decrease in the amount.
Benefit charges: Increase / decrease in claim reserves
Enter the increase or decrease in the amount of claim reserves between the prior and current years. Enter a negative number to indicate a decrease in the amount.
Benefit charges: Claims charged
Enter the amount of benefit claims charged but not paid against the premiums paid on the contracts.
Remainder of premium: Commissions / … / Other retention charges
Enter commissions, administrative service fees, other specific acquisition costs, other expenses, taxes, charges for risks or contingencies, and any other retention charges in the applicable fields.
Dividend / retroactive rate refunds / Paid in cash or credited
Enter the amount of dividends or retroactive rate refunds and indicate whether they were paid in cash or credited to the participants in experience-rated contracts.
Reserve status year end: Held to provide benefits
Enter the year-end balance of the reserve held to provide benefits to participants after retirement.
Reserve status year end: Claim reserves
Enter the year-end balance of the reserve held to provide benefits on future claims.
Reserve status year end: Other reserves
Enter the year-end balance of the reserve held for any other benefit not shown in the
Reserve status year end: Held to provide benefits and Claim reserves
fields.
Dividends or retroactive rate refunds due
Enter the amount of dividends or retroactive rate refunds that are due but have not been paid or credited.

Nonexperience-Rated Contracts

Costs related to contract or policy not included in Part I
Enter the nature and amount of any specific costs that the carrier, service, or other organization incurred in connection with the acquisition or retention of the contract that were not included in Schedule A, Part I.

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