# DocuSign Envelope ID: 36857BF5-BFB0-4F33-ACA9-8EE38BEA37BB
Chubb Global Casualty

**ISA H25579070**

| State | Estimated Policy Premium ($) | Initial AARO Adjustment ($) | Total Estimated Written Premium ($) |
|-------|------------------------------|----------------------------|------------------------------------|
| Arizona | 3,209 | 2,710 | 5,919 |
| Arkansas | 521 | 442 | 963 |
| California | 8,556 | (624) | 7,932 |
| Colorado | 2,970 | 2,492 | 5,462 |
| Florida | 18,502 | 0 | 18,502 |
| Georgia | 2,439 | 2,432 | 4,871 |
| Illinois | 4,197 | 3,911 | 8,108 |
| Indiana | 473 | 525 | 998 |
| Louisiana | 5,366 | 1,485 | 6,851 |
| Michigan | 471 | 331 | 802 |
| Minnesota | 806 | 1,016 | 1,822 |
| Mississippi | 676 | 526 | 1,202 |
| New Jersey | 1,462 | 1,173 | 2,635 |
| New Mexico | 444 | 339 | 783 |
| New York | 1,985 | 1,368 | 3,353 |
| North Carolina | 2,348 | 2,386 | 4,734 |
| Oregon | 645 | 0 | 645 |
| Tennessee | 1,923 | 1,620 | 3,543 |
| Texas | 9,820 | 7,030 | 16,850 |
| Virginia | 2,569 | 0 | 2,569 |
| Washington | 1,928 | 1,469 | 3,397 |
| Wisconsin | 408 | 671 | 1,079 |
| **TOTALS** | **71,718** | **31,302** | **103,020** |

## Totals - All Policies

| Policy Number(s) | Estimated Policy Premium ($) | Initial AARO Adjustment ($) | Total Estimated Written Premium ($) |
|------------------|------------------------------|----------------------------|------------------------------------|
| HDO G7296360A    | 82,032 | 120,468 | 202,500 |
| ISA H25579070     | 71,718 | 31,302 | 103,020 |
| **TOTALS**       | **153,750** | **151,770** | **305,520** |

**INTERNA_05212023_William Overby**
**04/28/2023**
**Initial Statement of Adjustment Page 25 of 55**