**Claim Stat Sheet**

**Date Prepared:** 6-4-82
**By:** DB

| CO. NAME | INSURED'S NAME | TYPE | CO. | PRODUCER CODE | CL. OFF | CASE | PREFIX | POLICY NUMBER | DATE OF LOSS | EFF. DATE |
|----------|----------------|------|-----|---------------|---------|-------|----------|--------------|-------------|-----------|
| Nu       | Total Policies |      |     |               |         |       |          |              |             |           |

**Payments and Reserve Recommendations**

| SYM | REPORT DATE | MAJOR CLASS | SEC | PROFIT UNIT | ADJ. NO. | DRAFT NUMBER | SUB TRAN | AMOUNT PAID | NEW REVISED RESERVE | STATUS | CL. CT. |
|-----|-------------|-------------|-----|-------------|----------|--------------|----------|--------------|---------------------|--------|---------|
| 32  | 13-36       | 37-39       | 40  | 41-43       | 44-46    | 47-52       | 53       | 3441        | 1110                | 62     | 63      |

**Div. Div. Tran.** | **Bene. State** | **Tax State** | **Spec. Filing Plan** | **Res. of Clm** | **Savings or Deficit** | **Proc. Code** |
|-------------------|----------------|--------------------|------------------|-----------------------|---------------|
| 11 72 73 74 75 76 | 73-76          | 77-79             | 80-81            | 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119-120 | 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141-144 | 147-153 154-155 156-157 158-159 160-161 | 1 76 |

**Reinsurance**

| REPC-IT DATE | MAJOR CLASS | SEC | PROFIT UNIT | SUB TRAN | AMOUNT PAID | NEW REVISED RESERVE | STATUS | REINS CO NO. | REMARKS |
|--------------|-------------|-----|-------------|----------|--------------|---------------------|--------|---------------|----------|
| 32-35        | 37-39       | 40  | 41-43       | 53       | 54-61       | 62 73          | 141-144 |               | 1110     |
| 6-4-82       |             |     |             |          |             |                   |         |               |           |

**Reserve Correction (To be used for all statistical changes except amount of reserve)**

| SYM | MAJOR CLASS | SUB TRAN | TRAN | TAX STATE | REINSURANCE CO. NO. | PLEASE CHANGE (ITEM) | FROM | TO |
|-----|-------------|----------|------|-----------|---------------------|----------------------|------|----|
| 32  | 37-39       | 73       |      | 75-76     | 141-144             |                      |      |    |

**Underwriting Copy**