# Reinsurance Continuation Sheet

**Policy Number:** 551-28-81

**Page:** 2 of 2

## Premium and Return Premium

| KIND | Trans. Eff. Date | TAX STATE | REINS. CO. CODE | MAJOR CLASS | REINS. COMM. RATE | PREMIUM OR RETURN | ANNIV. PREMIUM | FINAL EXP. YR. | REINS. SOURCE | REINS. CO. | REINS. % |
|------|------------------|-----------|----------------|-------------|--------------------|-------------------|----------------|---------------|--------------|------------|----------|
| 20   | 22               | 23-24     | 25             | 31-33       | 34-37              | 40-42             | 47-49           | 50-57         | 57           | 76-83      | 83        | 84-85    | 93-97    |
| 1    | 45               | 21        | 8              | 053         | 7856               | 001               | 300             | 22            | 00          | 16         | 18        | 00       |
| 2    | 4                 | 11        | 11             | 11          | 8803               | 002               | 300             | 16            | 00          | 18         | 00       |
| 3    | 4                 | 11        | 11             | 11          | 7857               | 663               | 320             | 18            | 00          | 50         | 00       |
| 4    | 6                 | 11        | 11             | 11          | 0871               | 004               | 250             | 50            | 00          | 00         | 00       |
| 5    | E                 |           |                |             |                    |                   |                 |               |              |            |          |

Misc. 2751 6/76