NJ Department of Banking & Insurance

Division of Insurance, Office of Property & Casualty

Private Passenger Automobile Excess Profit Report
N.J.A.C. 11:3-20
version 06/15/2010
Report Year 2020

NAIC Group # enter group # here Group Name enter group name here
NAIC Company #1 enter company #1 # here (or 0) Company Name enter company #1 name here
NAIC Company #2 enter company #2 # here (or 0) Company Name enter company #2 name here
NAIC Company #3 enter company #3 # here (or 0) Company Name enter company #3 name here
NAIC Company #4 enter company #4 # here (or 0) Company Name enter company #4 name here
NAIC Company #5 enter company #5 # here (or 0) Company Name enter company #5 name here
NAIC Company #6 enter company #6 # here (or 0) Company Name enter company #6 name here
NAIC Company #7 enter company #7 # here (or 0) Company Name enter company #7 name here
NAIC Company #8 enter company #8 # here (or 0) Company Name enter company #8 name here
NAIC Company #9 enter company #9 # here (or 0) Company Name enter company #9 name here
NAIC Company #10 enter company #10 # here (or 0) Company Name enter company #10 name here
NAIC Company #11 enter company #11 # here (or 0) Company Name enter company #11 name here
NAIC Company #12 enter company #12 # here (or 0) Company Name enter company #12 name here

Contact Person: Officer Certifying Survey: certify report below before submitting report
Name: enter here Name: enter here
Title: enter here Title: enter here
Telephone: enter here Telephone: enter here
E-Mail: enter here E-Mail: enter here

Certification (N.J.A.C. 11:3-20.5(e)):

I certify that the report complies with all statutory and regulatory requirements to the best of my knowledge and belief.
Date: enter date

Notes:
* E-Mail this report by July 1 to reports@dobi.nj.gov. Alternatively, report may be sent on CD-ROM or DVD-R to:
NJ Dept. of Banking & Insurance, Office of Property & Casualty, 20 W. State St., PO Box 325, Trenton, NJ 08625-0325
* Ensure that the AIRE codes and profit source/information is filled out on the InputA sheet.
* Please do not send in hard copies of this report and/or any cover letters or attachments (the latter two items are optional).
* Do not modify any exhibits or formulas in any way without contacting DOBI at the e-mail address above.
* Please note Special Instruction on InputTOTAL Tab regarding Exhibit 9, Source (16) due to Year 2018 Change in Federal
Corporate Income Tax Rate from 35 percent to 21 percent.
Comments: Include any changes in companies included with reasons why, and any other clarifying information.

10/30/2020 Cover Page

 A B C D E F G H I J K L M
1 Group Name: enter group name here Input Sheet
2 Group NAIC #: enter group # here Section A
3 Year Filed: 2020 PIP
4
5
6 Exhibit 1 Calendar Year
7 Source: Annual Statement - State Page Exhibit, Line 19.1 2019 2018 2017 2016 2015 2014 2013 2012 2011
8
9 Direct Written Premium
10 Col (1) Item 1 Total from the Annual Statement 0 0 0 0 0 0 0 0 0
11 Col (1) Item 2 Excluded Types included in Item 1 0 0 0 0 0 0 0 0 0
12 Col (1) Item 4 UCJF Assessments (19.1/PIP only) 0 0 0 0 0 0 0 0 0
13 0
14 Direct Earned Premium
15 Col (2) Item 1 Total from the Annual Statement 0 0 0 0 0 0 0 0 0
16 Col (2) Item 2 Excluded Types included in Item 1 0 0 0 0 0 0 0 0 0
17 Col (2) Item 4 UCJF Assessments (19.1/PIP only) 0 0 0 0 0 0 0 0 0
18 0
19 Paid Dividends (incl. Excess Profit Refunds)
20 Col (3A) Item 1 Total from the Annual Statement 0 0 0 0 0 0 0 0 0
21 Col (3A) Item 2 Excluded Types included in Item 1 0 0 0 0 0 0 0 0 0
22 0
23 Declared, but Unpaid Dividends (incl. Excess Profit Refunds)
24 Col (3B) Item 1 Total 0 0 0 0 0 0 0 0 0
25 Col (3B) Item 2 Excluded Types included in Item 1 0 0 0 0 0 0 0 0 0
26 0
27 Direct Unearned Premium Reserves
28 Col (4) Item 1 Total from the Annual Statement 0 0 0 0 0 0 0 0 0
29 Col (4) Item 2 Excluded Types included in Item 1 0 0 0 0 0 0 0 0 0
30 Col (4) Item 4 UCJF Assessments (19.1/PIP only) 0 0 0 0 0 0 0 0 0
31 0
32 Direct Unpaid Loss (Case + Bulk/IBNR)
33 Col (7) Item 1 Total from the Annual Statement 0 0 0 0 0 0 0 0 0
34 Col (7) Item 2 Excluded Types included in Item 1 0 0 0 0 0 0 0 0 0
35 Col (7) Item 4 Excess Medical Benefits 0 0 0 0 0 0 0 0 0
36 0
37 Direct Unpaid ALAE (Case +Bulk/IBNR)
38 Col (10) Item 1 Total from the Annual Statement 0 0 0 0 0 0 0 0 0
39 Col (10) Item 2 Excluded Types included in Item 1 0 0 0 0 0 0 0 0 0
40
41

10/30/2020 Page 2 of 52
 A B C D E F G H I J K L M
1 Group Name: enter group name here Input Sheet
2 Group NAIC #: enter group # here Section A
3 Year Filed: 2020 PIP
4
5
42 Exhibit 2
43
44 Part 1 Personal Injury Prot. Accident Year
45 Cumulative Incurred Loss and D&CCE as of 2011 2012 2013 2014 2015 2016 2017 2018 2019
46 15 months 0 0 0 0 0 0 0 0 0
47 27 months 0 0 0 0 0 0 0 0 XXX
48 39 months 0 0 0 0 0 0 0 XXX XXX
49 Please note that the years are 51 months 0 0 0 0 0 0 XXX XXX XXX
50 in reverse order of other sections of 63 months 0 0 0 0 0 XXX XXX XXX XXX
51 the Input Sheet. 75 months 0 0 0 0 XXX XXX XXX XXX XXX
52 87 months 0 0 0 XXX XXX XXX XXX XXX XXX
53 99 months 0 0 XXX XXX XXX XXX XXX XXX XXX
54
55
56
57
58
59
60
61
62
63
64
65
66 Part 2 Personal Injury Prot. Tail Factor (99 months-ultimate) 1.000 Provide Documentation if greater than 1.000
67
68
69 Part 3
70 Source: Countrywide Insurance Expense Exhibit (IEE) Part 3 Calendar Year
71 Line 19.1 (except Item 9) enter with trailing 000's 2019 2018 2017 2016 2015 2014 2013 2012 2011
72 Col (1) Direct Incurred Loss 0 0 0 0 0 0 0 0 0
73 Col (2) Direct Incurred Defense & Cost Containment Expense 0 0 0 0 0 0 0 0 0
74 Col (4) Direct Incurred Adjusting & Other Expense 0 0 0 0 0 0 0 0 0
75
76

10/30/2020 Page 3 of 52
 A B C D E F G H I J K L M
1 Group Name: enter group name here Input Sheet
2 Group NAIC #: enter group # here Section A
3 Year Filed: 2020 PIP
4
5
77 Exhibit 3 Calendar Year
78 Source: Countrywide Insurance Expense Exhibit (IEE) Part 3 2019 2018 2017 2016 2015 2014 2013 2012 2011
79 Line 19.1 (except Item 9) enter with trailing 000's
80 Col (1) Item 1 Direct Written Premium - CW 0 0 0 0 0 0 0 XXX XXX
81 Col (1) Item 2 Direct Earned Premium - CW 0 0 0 0 0 0 0 XXX XXX
82 Col (1) Item 3 Direct Other Acquisition Expense - CW 0 0 0 0 0 0 0 XXX XXX
83 Col (1) Item 4 Direct General Expense - CW 0 0 0 0 0 0 0 XXX XXX
84 Col (1) Item 5 Direct Commission & Brokerage - CW 0 0 0 0 0 0 0 XXX XXX
85 Col (1) Item 7 Direct Taxes, Licenses & Fees - CW 0 0 0 0 0 0 0 XXX XXX
86 Col (1) Item 9 Net Catastrophe Reinsurance Exp. - CW 0 0 0 0 0 0 0 XXX XXX
87
88 Source: Annual Statement - SPE, Line 19.1 (except Item 10)
89 Col (3) Item 5 Direct Commission & Brokerage - NJ 0 0 0 0 0 0 0 XXX XXX
90 Col (3) Item 7 Direct Taxes, Licenses & Fees - NJ 0 0 0 0 0 0 0 XXX XXX
91 Col (3) Item 9 Net Catastrophe Reinsurance Exp. - NJ 0 0 0 0 0 0 0 XXX XXX
92 Col (3) Item 10 LAD Fees Paid - NJ 0 0 0 0 0 0 0 XXX XXX
93
94

10/30/2020 Page 4 of 52
 A B C D E F G H I J K L M
1 Group Name: enter group name here Input Sheet
2 Group NAIC #: enter group # here Section B
3 Year Filed: 2020 Other Liability
4
5
6 Exhibit 1 Calendar Year
7 Source: Annual Statement - State Page Exhibit, Line 19.2 2019 2018 2017 2016 2015 2014 2013 2012 2011
8
9 Direct Written Premium
10 Col (1) Item 1 Total from the Annual Statement 0 0 0 0 0 0 0 0 0
11 Col (1) Item 2 Excluded Types included in Item 1 0 0 0 0 0 0 0 0 0
12 Col (1) Item 4 UCJF Assessments (19.1/PIP only) XXX XXX XXX XXX XXX XXX XXX XXX XXX
13
14 Direct Earned Premium
15 Col (2) Item 1 Total from the Annual Statement 0 0 0 0 0 0 0 0 0
16 Col (2) Item 2 Excluded Types included in Item 1 0 0 0 0 0 0 0 0 0
17 Col (2) Item 4 UCJF Assessments (19.1/PIP only) XXX XXX XXX XXX XXX XXX XXX XXX XXX
18
19 Paid Dividends (incl. Excess Profit Refunds)
20 Col (3A) Item 1 Total from the Annual Statement 0 0 0 0 0 0 0 0 0
21 Col (3A) Item 2 Excluded Types included in Item 1 0 0 0 0 0 0 0 0 0
22
23 Declared, but Unpaid Dividends (incl. Excess Profit Refunds)
24 Col (3B) Item 1 Total 0 0 0 0 0 0 0 0 0
25 Col (3B) Item 2 Excluded Types included in Item 1 0 0 0 0 0 0 0 0 0
26
27 Direct Unearned Premium Reserves
28 Col (4) Item 1 Total from the Annual Statement 0 0 0 0 0 0 0 0 0
29 Col (4) Item 2 Excluded Types included in Item 1 0 0 0 0 0 0 0 0 0
30 Col (4) Item 4 UCJF Assessments (19.1/PIP only) XXX XXX XXX XXX XXX XXX XXX XXX XXX
31
32 Direct Unpaid Loss (Case + Bulk/IBNR)
33 Col (7) Item 1 Total from the Annual Statement 0 0 0 0 0 0 0 0 0
34 Col (7) Item 2 Excluded Types included in Item 1 0 0 0 0 0 0 0 0 0
35 Col (7) Item 4 Excess Medical Benefits XXX XXX XXX XXX XXX XXX XXX XXX XXX
36
37 Direct Unpaid ALAE (Case +Bulk/IBNR)
38 Col (10) Item 1 Total from the Annual Statement 0 0 0 0 0 0 0 0 0
39 Col (10) Item 2 Excluded Types included in Item 1 0 0 0 0 0 0 0 0 0
40
41

10/30/2020 Page 5 of 52
 A B C D E F G H I J K L M
1 Group Name: enter group name here Input Sheet
2 Group NAIC #: enter group # here Section B
3 Year Filed: 2020 Other Liability
4
5
42 Exhibit 2
43
44 Part 1 Bodily Injury Accident Year
45 Cumulative Incurred Loss and D&CCE as of 2011 2012 2013 2014 2015 2016 2017 2018 2019
46 15 months 0 0 0 0 0 0 0 0 0
47 27 months 0 0 0 0 0 0 0 0 XXX
48 39 months 0 0 0 0 0 0 0 XXX XXX
49 Please note that the years are 51 months 0 0 0 0 0 0 XXX XXX XXX
50 in reverse order of other sections of 63 months 0 0 0 0 0 XXX XXX XXX XXX
51 the Input Sheet. 75 months 0 0 0 0 XXX XXX XXX XXX XXX
52 87 months 0 0 0 XXX XXX XXX XXX XXX XXX
53 99 months 0 0 XXX XXX XXX XXX XXX XXX XXX
54
55 Part 1 Property Damage Accident Year
56 Cumulative Incurred Loss and D&CCE as of 2011 2012 2013 2014 2015 2016 2017 2018 2019
57 15 months 0 0 0 0 0 0 0 0 0
58 27 months 0 0 0 0 0 0 0 0
59 39 months 0 0 0 0 0 0 0 XXX XXX
60 Please note that the years are 51 months 0 0 0 0 0 0 XXX XXX XXX
61 in reverse order of other sections of
62 the Input Sheet.
63
64
65
66 Part 2 Bodily Injury Tail Factor (99 months-ultimate) 1.000 Provide Documentation if greater than 1.000
67
68
69 Part 3
70 Source: Countrywide Insurance Expense Exhibit (IEE) Part 3 Calendar Year
71 Line 19.1 (except Item 9) enter with trailing 000's 2019 2018 2017 2016 2015 2014 2013 2012 2011
72 Col (1) Direct Incurred Loss 0 0 0 0 0 0 0 0 0
73 Col (2) Direct Incurred Defense & Cost Containment Expense 0 0 0 0 0 0 0 0 0
74 Col (4) Direct Incurred Adjusting & Other Expense 0 0 0 0 0 0 0 0 0
75
76

10/30/2020 Page 6 of 52
 A B C D E F G H I J K L M
1 Group Name: enter group name here Input Sheet
2 Group NAIC #: enter group # here Section B
3 Year Filed: 2020 Other Liability
4
5
77 Exhibit 3 Calendar Year
78 Source: Countrywide Insurance Expense Exhibit (IEE) Part 3 2019 2018 2017 2016 2015 2014 2013 2012 2011
79 Line 19.1 (except Item 9) enter with trailing 000's
80 Col (1) Item 1 Direct Written Premium - CW 0 0 0 0 0 0 0 XXX XXX
81 Col (1) Item 2 Direct Earned Premium - CW 0 0 0 0 0 0 0 XXX XXX
82 Col (1) Item 3 Direct Other Acquisition Expense - CW 0 0 0 0 0 0 0 XXX XXX
83 Col (1) Item 4 Direct General Expense - CW 0 0 0 0 0 0 0 XXX XXX
84 Col (1) Item 5 Direct Commission & Brokerage - CW 0 0 0 0 0 0 0 XXX XXX
85 Col (1) Item 7 Direct Taxes, Licenses & Fees - CW 0 0 0 0 0 0 0 XXX XXX
86 Col (1) Item 9 Net Catastrophe Reinsurance Exp. - CW 0 0 0 0 0 0 0 XXX XXX
87
88 Source: Annual Statement - SPE, Line 19.2 (except Item 10)
89 Col (3) Item 5 Direct Commission & Brokerage - NJ 0 0 0 0 0 0 0 XXX XXX
90 Col (3) Item 7 Direct Taxes, Licenses & Fees - NJ 0 0 0 0 0 0 0 XXX XXX
91 Col (3) Item 9 Net Catastrophe Reinsurance Exp. - NJ 0 0 0 0 0 0 0 XXX XXX
92 Col (3) Item 10 LAD Fees Paid - NJ 0 0 0 0 0 0 0 XXX XXX
93
94

10/30/2020 Page 7 of 52
 A B C D E F G H I J K L M
1 Group Name: enter group name here Input Sheet
2 Group NAIC #: enter group # here Section C
3 Year Filed: 2020 Phys Damage
4
5
6 Exhibit 1 Calendar Year
7 Source: Annual Statement - State Page Exhibit, Line 21.1 2019 2018 2017 2016 2015 2014 2013 2012 2011
8
9 Direct Written Premium
10 Col (1) Item 1 Total from the Annual Statement 0 0 0 0 0 0 0 0 0
11 Col (1) Item 2 Excluded Types included in Item 1 0 0 0 0 0 0 0 0 0
12 Col (1) Item 4 UCJF Assessments (19.1/PIP only) XXX XXX XXX XXX XXX XXX XXX XXX XXX
13 0
14 Direct Earned Premium
15 Col (2) Item 1 Total from the Annual Statement 0 0 0 0 0 0 0 0 0
16 Col (2) Item 2 Excluded Types included in Item 1 0 0 0 0 0 0 0 0 0
17 Col (2) Item 4 UCJF Assessments (19.1/PIP only) XXX XXX XXX XXX XXX XXX XXX XXX XXX
18 0
19 Paid Dividends (incl. Excess Profit Refunds)
20 Col (3A) Item 1 Total from the Annual Statement 0 0 0 0 0 0 0 0 0
21 Col (3A) Item 2 Excluded Types included in Item 1 0 0 0 0 0 0 0 0 0
22 0
23 Declared, but Unpaid Dividends (incl. Excess Profit Refunds)
24 Col (3B) Item 1 Total 0 0 0 0 0 0 0 0 0
25 Col (3B) Item 2 Excluded Types included in Item 1 0 0 0 0 0 0 0 0 0
26 0
27 Direct Unearned Premium Reserves
28 Col (4) Item 1 Total from the Annual Statement 0 0 0 0 0 0 0 0 0
29 Col (4) Item 2 Excluded Types included in Item 1 0 0 0 0 0 0 0 0 0
30 Col (4) Item 4 UCJF Assessments (19.1/PIP only) XXX XXX XXX XXX XXX XXX XXX XXX XXX
31 0
32 Direct Unpaid Loss (Case + Bulk/IBNR)
33 Col (7) Item 1 Total from the Annual Statement 0 0 0 0 0 0 0 0 0
34 Col (7) Item 2 Excluded Types included in Item 1 0 0 0 0 0 0 0 0 0
35 Col (7) Item 4 Excess Medical Benefits XXX XXX XXX XXX XXX XXX XXX XXX XXX
36 0
37 Direct Unpaid ALAE (Case +Bulk/IBNR)
38 Col (10) Item 1 Total from the Annual Statement 0 0 0 0 0 0 0 0 0
39 Col (10) Item 2 Excluded Types included in Item 1 0 0 0 0 0 0 0 0 0
40
41
42 Exhibit 2
43
44 Part 1 Physical Damage Accident Year
45 Cumulative Incurred Loss and D&CCE as of 2011 2012 2013 2014 2015 2016 2017 2018 2019
46 15 months 0 0 0 0 0 0 0 0 0
47 27 months 0 0 0 0 0 0 0 0 XXX
48 39 months 0 0 0 0 0 0 0 XXX XXX
49 Please note that the years are 51 months 0 0 0 0 0 0 XXX XXX XXX
50 in reverse order of other sections of
51 the Input Sheet.
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66 Part 2 Physical Damage Tail Factor (51 months-ultimate) 1.000 Provide Documentation if greater than 1.000
67
68
69 Part 3
70 Source: Countrywide Insurance Expense Exhibit (IEE) Part 3 Calendar Year
71 Part 3, Line 21.1 (except Item 9) enter with trailing 000's 2019 2018 2017 2016 2015 2014 2013 2012 2011
72 Col (1) Direct Incurred Loss 0 0 0 0 0 0 0 0 0
73 Col (2) Direct Incurred Defense & Cost Containment Expense 0 0 0 0 0 0 0 0 0

10/30/2020 Page 8 of 52
 A B C D E F G H I J K L M
1 Group Name: enter group name here Input Sheet
2 Group NAIC #: enter group # here Section C
3 Year Filed: 2020 Phys Damage
4
5
74 Col (4) Direct Incurred Adjusting & Other Expense 0 0 0 0 0 0 0 0 0
75
76

10/30/2020 Page 9 of 52
 A B C D E F G H I J K L M
1 Group Name: enter group name here Input Sheet
2 Group NAIC #: enter group # here Section C
3 Year Filed: 2020 Phys Damage
4
5
77 Exhibit 3 Calendar Year
78 Source: Countrywide Insurance Expense Exhibit (IEE) Part 3 2019 2018 2017 2016 2015 2014 2013 2012 2011
79 Part 3, Line 21.1 (except Item 9) enter with trailing 000's
80 Col (1) Item 1 Direct Written Premium - CW 0 0 0 0 0 0 0 XXX XXX
81 Col (1) Item 2 Direct Earned Premium - CW 0 0 0 0 0 0 0 XXX XXX
82 Col (1) Item 3 Direct Other Acquisition Expense - CW 0 0 0 0 0 0 0 XXX XXX
83 Col (1) Item 4 Direct General Expense - CW 0 0 0 0 0 0 0 XXX XXX
84 Col (1) Item 5 Direct Commission & Brokerage - CW 0 0 0 0 0 0 0 XXX XXX
85 Col (1) Item 7 Direct Taxes, Licenses & Fees - CW 0 0 0 0 0 0 0 XXX XXX
86 Col (1) Item 9 Net Catastrophe Reinsurance Exp. - CW 0 0 0 0 0 0 0 XXX XXX
87
88 Source: Annual Statement - SPE, Line 21,1 (except Item 10)
89 Col (3) Item 5 Direct Commission & Brokerage - NJ 0 0 0 0 0 0 0 XXX XXX
90 Col (3) Item 7 Direct Taxes, Licenses & Fees - NJ 0 0 0 0 0 0 0 XXX XXX
91 Col (3) Item 9 Net Catastrophe Reinsurance Exp. - NJ 0 0 0 0 0 0 0 XXX XXX
92 Col (3) Item 10 LAD Fees Paid - NJ 0 0 0 0 0 0 0 XXX XXX
93
94

10/30/2020 Page 10 of 52
 A B C D E F G H I J K L M
1 Group Name: enter group name here Input Sheet
2 Group NAIC #: enter group # here Section T
3 Year Filed: 2020 All Coverages
4
5
173 Calendar Year Reinvestment into New Jersey
174 2011 2010 2009 2008 2007 2006 2005 2004
175 Reinvestment into New Jersey
176 Item 1 0.00 0 0 0 0 0 0 0 0
177
178 Reinvestment Carryforward Used Total Carryforward Used: 0 0 0 0 0 0 0 0
179 Item 2.1 in AY 2019 0 0 0 0 0 0 0 0
180 Item 2.2 in AY 2018 0 0 0 0 0 0 0 0
181 Item 2.3 in AY 2017 0 0 0 0 0 0 0 0
182 Item 2.4 in AY 2016 0 0 0 0 0 0 0 0
183 Item 2.5 in AY 2015 0 0 0 0 0 0 0 0
184 Item 2.6 in AY 2014 0 0 0 0 0 0 0 0
185 Item 2.7 in AY 2013 0 0 0 0 0 0 0 0
186 Item 2.8 in AY 2012 0 0 0 0 0 0 0 0
187 Item 2.9 in AY 2011 0 0 0 0 0 0 0 0
188 Item 2.10 in AY 2010 0 0 0 0 0 0 0 0
189 Item 2.15 in AY 2009 0 0 0 0 0 0 0 0
190 Item 2.12 in AY 2008 0 0 0 0 0 0 0 0
191 Item 2.13 in AY 2007 0 0 0 0 0 0 0 0
192 Item 2.14 in AY 2006 0 0 0 0 0 0 0 0
193 Item 2.15 in AY 2005 0 0 0 0 0 0 0 0
194 Item 2.16 in AY 2004 0 0 0 0 0 0 0 0
195 Item 2.17 in AY 2003 XXX 0 0 0 0 0 0 0
196 Item 2.18 in AY 2002 XXX XXX 0 0 0 0 0 0
197 Item 2.19 in AY 2001 XXX XXX XXX 0 0 0 0 0
198 Item 2.20 in AY 2000 XXX XXX XXX XXX 0 0 0 0
199 Item 2.21 in AY 1999 XXX XXX XXX XXX XXX 0 0 0
200 Item 2.22 in AY 1998 XXX XXX XXX XXX XXX XXX 0 0
201 Item 2.23 in AY 1997 XXX XXX XXX XXX XXX XXX XXX 0
202
203
204 Special Instructions for Exhibit 9, Source (16) section:
205
206 * For Year 2017 and Prior column, filer could input in figures from the 2018 Excess Profit Report or from the most recent PPA Approval filing submitted and approved in or before Year 2017.
207
208 * For Year 2018 and Subsequent column, filer should input in figures from the most recent PPA Prior Approval filing submitted and approved in or after Year 2018.
209
210
211
212
213 Exhibit 9 To remove red highlight from cells, enter the reference in the line below by overwriting the blue text in the Source lines
214 Source (4) Enter AIRE Codes Used by Insurer enter code or 0000 enter code or 0000 enter code or 0000 enter code or 0000 enter code or 0000
215 Calendar Year as of March 31
216 2019 2018 2017 2016 2015 2014 2013
217 Item 4A AIRE Assessment Allocation
218 Item 4B AIRE Redistribution of Investment Inc.
219 Item 4C AIRE Assessment at Present Rate
220 Source (16) Source for Item 16 Entries enter reference(s) where data for Exhibit 9 Item 16 can be found (or indicate if an exhibit is attached)
Year 2017 and Year 2018 and
221
PRIOR SUBSEQUENT
222 Item 16A After-Tax Target Return on Surplus enter enter 1. If using same formula as here in last rate filing, then provide the NJ filing # and page reference # in cell F211.
223 Item 16B After-Tax Investment Income on Surplus enter enter 2. If using same formula as here in a prior rate filing but w/ updated values, then provide the NJ filing #, page reference #, and updated values w/ support.
224 Item 16C Premium to Surplus Ratio enter enter 3. If using a different formula in an approved rate filing than Is used here, provide the filing's profit loading, NJ filing #, and page reference # in cell F211.
225 Item 19 Development Adjustment 0 Provide Documentation if greater than 0. This item is optional.

10/30/2020 Page 11 of 52
 A B C D E F G H I J
1 Group Name: enter group name here Exhibit 1A
2 Group NAIC #: enter group # here PIP
3 Year Filed: 2020 Sheet 1
4
5 Calendar Year 2019 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
6 0 0 Direct Direct Dividends Direct Direct Direct
7 0 0 Written Earned on Direct Unearned Unpaid Unpaid
8 0 0 Premium Premium Business Premium Losses D&CCE
9 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
10 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
11 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
12 Item 4 UCJF Assessments & Excess Medical Benefits 0 0 XXX 0 0 XXX
13
14 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
15 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
16
17 Calendar Year 2018 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
18 Direct Direct Dividends Direct Direct Direct
19 Written Earned on Direct Unearned Unpaid Unpaid
20 Premium Premium Business Premium Losses D&CCE
21 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
22 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
23 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
24 Item 4 UCJF Assessments & Excess Medical Benefits 0 0 XXX 0 0 XXX
25
26 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
27 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
28
29 Calendar Year 2017 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
30 Direct Direct Dividends Direct Direct Direct
31 Written Earned on Direct Unearned Unpaid Unpaid
32 Premium Premium Business Premium Losses D&CCE
33 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
34 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
35 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
36 Item 4 UCJF Assessments & Excess Medical Benefits 0 0 XXX 0 0 XXX
37
38 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
39 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
40
41

10/30/2020 Page 10 of 52
 A B C D E F G H I J
42 Group Name: enter group name here Exhibit 1A
43 Group NAIC #: enter group # here PIP
44 Year Filed: 2020 Sheet 2
45
46 Calendar Year 2016 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
47 Direct Direct Dividends Direct Direct Direct
48 Written Earned on Direct Unearned Unpaid Unpaid
49 Premium Premium Business Premium Losses D&CCE
50 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
51 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
52 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
53 Item 4 UCJF Assessments & Excess Medical Benefits 0 0 XXX 0 0 XXX
54
55 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
56 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
57
58 Calendar Year 2015 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
59 Direct Direct Dividends Direct Direct Direct
60 Written Earned on Direct Unearned Unpaid Unpaid
61 Premium Premium Business Premium Losses D&CCE
62 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
63 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
64 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
65 Item 4 UCJF Assessments & Excess Medical Benefits 0 0 XXX 0 0 XXX
66
67 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
68 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
69
70 Calendar Year 2014 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
71 Direct Direct Dividends Direct Direct Direct
72 Written Earned on Direct Unearned Unpaid Unpaid
73 Premium Premium Business Premium Losses D&CCE
74 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
75 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
76 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
77 Item 4 UCJF Assessments & Excess Medical Benefits 0 0 XXX 0 0 XXX
78
79 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
80 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
81
82

10/30/2020 Page 11 of 52
 A B C D E F G H I J
83 Group Name: enter group name here Exhibit 1A
84 Group NAIC #: enter group # here PIP
85 Year Filed: 2020 Sheet 3
86
87 Calendar Year 2013 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
88 Direct Direct Dividends Direct Direct Direct
89 Written Earned on Direct Unearned Unpaid Unpaid
90 Premium Premium Business Premium Losses D&CCE
91 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
92 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
93 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
94 Item 4 UCJF Assessments & Excess Medical Benefits 0 0 XXX 0 0 XXX
95
96 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
97 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
98
99 Calendar Year 2012 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
100 Direct Direct Dividends Direct Direct Direct
101 Written Earned on Direct Unearned Unpaid Unpaid
102 Premium Premium Business Premium Losses D&CCE
103 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
104 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
105 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
106 Item 4 UCJF Assessments & Excess Medical Benefits 0 0 XXX 0 0 XXX
107
108 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
109 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
110
111 Calendar Year 2011 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
112 Direct Direct Dividends Direct Direct Direct
113 Written Earned on Direct Unearned Unpaid Unpaid
114 Premium Premium Business Premium Losses D&CCE
115 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
116 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
117 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
118 Item 4 UCJF Assessments & Excess Medical Benefits 0 0 XXX 0 0 XXX
119
120 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
121 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
122
123

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 A B C D E F G H I J
1 Group Name: enter group name here Exhibit 1B
2 Group NAIC #: enter group # here Other Liability
3 Year Filed: 2020 Sheet 1
4
5 Calendar Year 2019 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
6 Direct Direct Dividends Direct Direct Direct
7 Written Earned on Direct Unearned Unpaid Unpaid
8 Premium Premium Business Premium Losses D&CCE
9 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
10 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
11 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
12 Item 4 UCJF Assessments & Excess Medical Benefits XXX XXX XXX XXX XXX XXX
13
14 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
15 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
16
17 Calendar Year 2018 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
18 Direct Direct Dividends Direct Direct Direct
19 Written Earned on Direct Unearned Unpaid Unpaid
20 Premium Premium Business Premium Losses D&CCE
21 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
22 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
23 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
24 Item 4 UCJF Assessments & Excess Medical Benefits XXX XXX XXX XXX XXX XXX
25
26 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
27 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
28
29 Calendar Year 2017 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
30 Direct Direct Dividends Direct Direct Direct
31 Written Earned on Direct Unearned Unpaid Unpaid
32 Premium Premium Business Premium Losses D&CCE
33 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
34 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
35 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
36 Item 4 UCJF Assessments & Excess Medical Benefits XXX XXX XXX XXX XXX XXX
37
38 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
39 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
40
41

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 A B C D E F G H I J
42 Group Name: enter group name here Exhibit 1B
43 Group NAIC #: enter group # here Other Liability
44 Year Filed: 2020 Sheet 2
45
46 Calendar Year 2016 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
47 Direct Direct Dividends Direct Direct Direct
48 Written Earned on Direct Unearned Unpaid Unpaid
49 Premium Premium Business Premium Losses D&CCE
50 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
51 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
52 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
53 Item 4 UCJF Assessments & Excess Medical Benefits XXX XXX XXX XXX XXX XXX
54
55 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
56 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
57
58 Calendar Year 2015 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
59 Direct Direct Dividends Direct Direct Direct
60 Written Earned on Direct Unearned Unpaid Unpaid
61 Premium Premium Business Premium Losses D&CCE
62 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
63 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
64 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
65 Item 4 UCJF Assessments & Excess Medical Benefits XXX XXX XXX XXX XXX XXX
66
67 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
68 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
69
70 Calendar Year 2014 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
71 Direct Direct Dividends Direct Direct Direct
72 Written Earned on Direct Unearned Unpaid Unpaid
73 Premium Premium Business Premium Losses D&CCE
74 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
75 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
76 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
77 Item 4 UCJF Assessments & Excess Medical Benefits XXX XXX XXX XXX XXX XXX
78
79 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
80 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
81
82

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 A B C D E F G H I J
83 Group Name: enter group name here Exhibit 1B
84 Group NAIC #: enter group # here Other Liability
85 Year Filed: 2020 Sheet 3
86
87 Calendar Year 2013 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
88 Direct Direct Dividends Direct Direct Direct
89 Written Earned on Direct Unearned Unpaid Unpaid
90 Premium Premium Business Premium Losses D&CCE
91 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
92 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
93 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
94 Item 4 UCJF Assessments & Excess Medical Benefits XXX XXX XXX XXX XXX XXX
95
96 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
97 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
98
99 Calendar Year 2012 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
100 Direct Direct Dividends Direct Direct Direct
101 Written Earned on Direct Unearned Unpaid Unpaid
102 Premium Premium Business Premium Losses D&CCE
103 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
104 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
105 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
106 Item 4 UCJF Assessments & Excess Medical Benefits XXX XXX XXX XXX XXX XXX
107
108 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
109 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
110
111 Calendar Year 2011 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
112 Direct Direct Dividends Direct Direct Direct
113 Written Earned on Direct Unearned Unpaid Unpaid
114 Premium Premium Business Premium Losses D&CCE
115 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
116 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
117 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
118 Item 4 UCJF Assessments & Excess Medical Benefits XXX XXX XXX XXX XXX XXX
119
120 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
121 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
122
123

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 A B C D E F G H I J
1 Group Name: enter group name here Exhibit 1C
2 Group NAIC #: enter group # here Phys Damage
3 Year Filed: 2020 Sheet 1
4
5 Calendar Year 2019 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
6 0 0 Direct Direct Dividends Direct Direct Direct
7 0 0 Written Earned on Direct Unearned Unpaid Unpaid
8 0 0 Premium Premium Business Premium Losses D&CCE
9 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
10 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
11 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
12 Item 4 UCJF Assessments & Excess Medical Benefits XXX XXX XXX XXX XXX XXX
13
14 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
15 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
16
17 Calendar Year 2018 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
18 Direct Direct Dividends Direct Direct Direct
19 Written Earned on Direct Unearned Unpaid Unpaid
20 Premium Premium Business Premium Losses D&CCE
21 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
22 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
23 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
24 Item 4 UCJF Assessments & Excess Medical Benefits XXX XXX XXX XXX XXX XXX
25
26 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
27 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
28
29 Calendar Year 2017 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
30 Direct Direct Dividends Direct Direct Direct
31 Written Earned on Direct Unearned Unpaid Unpaid
32 Premium Premium Business Premium Losses D&CCE
33 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
34 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
35 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
36 Item 4 UCJF Assessments & Excess Medical Benefits XXX XXX XXX XXX XXX XXX
37
38 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
39 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
40
41

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 A B C D E F G H I J
42 Group Name: enter group name here Exhibit 1C
43 Group NAIC #: enter group # here Phys Damage
44 Year Filed: 2020 Sheet 2
45
46 Calendar Year 2016 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
47 Direct Direct Dividends Direct Direct Direct
48 Written Earned on Direct Unearned Unpaid Unpaid
49 Premium Premium Business Premium Losses D&CCE
50 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
51 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
52 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
53 Item 4 UCJF Assessments & Excess Medical Benefits XXX XXX XXX XXX XXX XXX
54
55 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
56 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
57
58 Calendar Year 2015 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
59 Direct Direct Dividends Direct Direct Direct
60 Written Earned on Direct Unearned Unpaid Unpaid
61 Premium Premium Business Premium Losses D&CCE
62 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
63 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
64 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
65 Item 4 UCJF Assessments & Excess Medical Benefits XXX XXX XXX XXX XXX XXX
66
67 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
68 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
69
70 Calendar Year 2014 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
71 Direct Direct Dividends Direct Direct Direct
72 Written Earned on Direct Unearned Unpaid Unpaid
73 Premium Premium Business Premium Losses D&CCE
74 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
75 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
76 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
77 Item 4 UCJF Assessments & Excess Medical Benefits XXX XXX XXX XXX XXX XXX
78
79 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
80 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
81
82

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 A B C D E F G H I J
83 Group Name: enter group name here Exhibit 1C
84 Group NAIC #: enter group # here Phys Damage
85 Year Filed: 2020 Sheet 3
86
87 Calendar Year 2013 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
88 Direct Direct Dividends Direct Direct Direct
89 Written Earned on Direct Unearned Unpaid Unpaid
90 Premium Premium Business Premium Losses D&CCE
91 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
92 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
93 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
94 Item 4 UCJF Assessments & Excess Medical Benefits XXX XXX XXX XXX XXX XXX
95
96 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
97 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
98
99 Calendar Year 2012 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
100 Direct Direct Dividends Direct Direct Direct
101 Written Earned on Direct Unearned Unpaid Unpaid
102 Premium Premium Business Premium Losses D&CCE
103 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
104 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
105 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
106 Item 4 UCJF Assessments & Excess Medical Benefits XXX XXX XXX XXX XXX XXX
107
108 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
109 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
110
111 Calendar Year 2011 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
112 Direct Direct Dividends Direct Direct Direct
113 Written Earned on Direct Unearned Unpaid Unpaid
114 Premium Premium Business Premium Losses D&CCE
115 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
116 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
117 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
118 Item 4 UCJF Assessments & Excess Medical Benefits XXX XXX XXX XXX XXX XXX
119
120 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX XXX XXX XXX XXX
121 Item 6 All Other Dividends, included in Col (3) XXX XXX XXX XXX XXX XXX
122
123

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 A B C D E F G H I J
1 Group Name: enter group name here Exhibit 1
2 Group NAIC #: enter group # here All Coverages
3 Year Filed: 2020 Sheet 1
4
5 Calendar Year 2019 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
6 0 0 Direct Direct Dividends Direct Direct Direct
7 0 0 Written Earned on Direct Unearned Unpaid Unpaid
8 0 0 Premium Premium Business Premium Losses D&CCE
9 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
10 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
11 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
12 Item 4 UCJF Assessments & Excess Medical Benefits 0 0 0 0 0 XXX
13 Item 3-4 0 0 0 0 0 #VALUE!
14 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX 0 XXX XXX XXX
15 Item 6 All Other Dividends, included in Col (3) XXX XXX 0 XXX XXX XXX
16
17 Calendar Year 2018 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
18 Direct Direct Dividends Direct Direct Direct
19 Written Earned on Direct Unearned Unpaid Unpaid
20 Premium Premium Business Premium Losses D&CCE
21 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
22 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
23 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
24 Item 4 UCJF Assessments & Excess Medical Benefits 0 0 0 0 0 XXX
25 Item 3-4 0 0 0 0 0 #VALUE!
26 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX 0 XXX XXX XXX
27 Item 6 All Other Dividends, included in Col (3) XXX XXX 0 XXX XXX XXX
28
29 Calendar Year 2017 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
30 Direct Direct Dividends Direct Direct Direct
31 Written Earned on Direct Unearned Unpaid Unpaid
32 Premium Premium Business Premium Losses D&CCE
33 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
34 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
35 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
36 Item 4 UCJF Assessments & Excess Medical Benefits 0 0 0 0 0 XXX
37 Item 3-4 0 0 0 0 0 #VALUE!
38 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX 0 XXX XXX XXX
39 Item 6 All Other Dividends, included in Col (3) XXX XXX 0 XXX XXX XXX
40
41

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 A B C D E F G H I J
42 Group Name: enter group name here Exhibit 1
43 Group NAIC #: enter group # here All Coverages
44 Year Filed: 2020 Sheet 2
45
46 Calendar Year 2016 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
47 Direct Direct Dividends Direct Direct Direct
48 Written Earned on Direct Unearned Unpaid Unpaid
49 Premium Premium Business Premium Losses D&CCE
50 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
51 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
52 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
53 Item 4 UCJF Assessments & Excess Medical Benefits 0 0 0 0 0 XXX
54 Item 3-4 0 0 0 0 0 #VALUE!
55 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX 0 XXX XXX XXX
56 Item 6 All Other Dividends, included in Col (3) XXX XXX 0 XXX XXX XXX
57
58 Calendar Year 2015 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
59 Direct Direct Dividends Direct Direct Direct
60 Written Earned on Direct Unearned Unpaid Unpaid
61 Premium Premium Business Premium Losses D&CCE
62 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
63 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
64 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
65 Item 4 UCJF Assessments & Excess Medical Benefits 0 0 0 0 0 XXX
66 Item 3-4 0 0 0 0 0 #VALUE!
67 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX 0 XXX XXX XXX
68 Item 6 All Other Dividends, included in Col (3) XXX XXX 0 XXX XXX XXX
69
70 Calendar Year 2014 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
71 Direct Direct Dividends Direct Direct Direct
72 Written Earned on Direct Unearned Unpaid Unpaid
73 Premium Premium Business Premium Losses D&CCE
74 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
75 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
76 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
77 Item 4 UCJF Assessments & Excess Medical Benefits 0 0 0 0 0 0
78 Item 3-4 0 0 0 0 0 0
79 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX 0 XXX XXX 0
80 Item 6 All Other Dividends, included in Col (3) XXX XXX 0 XXX XXX 0
81
82

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 A B C D E F G H I J
83 Group Name: enter group name here Exhibit 1
84 Group NAIC #: enter group # here All Coverages
85 Year Filed: 2020 Sheet 3
86
87 Calendar Year 2013 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
88 Direct Direct Dividends Direct Direct Direct
89 Written Earned on Direct Unearned Unpaid Unpaid
90 Premium Premium Business Premium Losses D&CCE
91 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
92 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
93 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
94 Item 4 UCJF Assessments & Excess Medical Benefits 0 0 0 0 0 0
95 Item 3-4 0 0 0 0 0 0
96 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX 0 XXX XXX 0
97 Item 6 All Other Dividends, included in Col (3) XXX XXX 0 XXX XXX 0
98
99 Calendar Year 2012 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
100 Direct Direct Dividends Direct Direct Direct
101 Written Earned on Direct Unearned Unpaid Unpaid
102 Premium Premium Business Premium Losses D&CCE
103 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
104 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
105 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
106 Item 4 UCJF Assessments & Excess Medical Benefits 0 0 0 0 0 0
107 Item 3-4 0 0 0 0 0 0
108 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX 0 XXX XXX 0
109 Item 6 All Other Dividends, included in Col (3) XXX XXX 0 XXX XXX 0
110
111 Calendar Year 2011 Col (1) Col (2) Col (3) Col (4) Col (5) Col (6)
112 Direct Direct Dividends Direct Direct Direct
113 Written Earned on Direct Unearned Unpaid Unpaid
114 Premium Premium Business Premium Losses D&CCE
115 Item 1 Total as Reported on State Page Exhibit 0 0 0 0 0 0
116 Item 2 Exclusions Reported on State Page Exhibit 0 0 0 0 0 0
117 Item 3 Excess Profit Data [Item 1 - Item 2] 0 0 0 0 0 0
118 Item 4 UCJF Assessments & Excess Medical Benefits 0 0 0 0 0 0
119 Item 3-4 0 0 0 0 0 0
120 Item 5 Refund of Excess Profit, included in Col (3) XXX XXX 0 XXX XXX 0
121 Item 6 All Other Dividends, included in Col (3) XXX XXX 0 XXX XXX 0
122
123

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 A B C D E F G H I J K L
1 Group Name: enter group name here Exhibit 2A
2 Group NAIC #: enter group # here PIP
3 Year Filed: 2020
4
5 Part 1
6 Cum. Case Inc.
7 Loss + ALAE Accident Year
8 as of 2011 2012 2013 2014 2015 2016 2017 2018 2019
9 15 months 0 0 0 0 0 0 0 0 0
10 27 months 0 0 0 0 0 0 0 0
11 39 months 0 0 0 0 0 0 0
12 51 months 0 0 0 0 0 0
13 63 months 0 0 0 0 0
14 75 months 0 0 0 0
15 87 months 0 0 0
16 99 months 0 0
17
18 Part 2 Col (A) Col (B)
19 Development Accident Year Incremental Development Cumulative
20 Factors 2011 2012 2013 2014 2015 2016 2017 2018 LDF Factors LDF
21 15-27 months ----- ----- ----- ----- ----- ----- ----- ----- 1.000 15 mo. - ult. 1.000
22 27-39 months ----- ----- ----- ----- ----- ----- ----- 1.000 27 mo. - ult. 1.000
23 39-51 months ----- ----- ----- ----- ----- ----- 1.000 39 mo. - ult. 1.000
24 51-63 months ----- ----- ----- ----- ----- 1.000 51 mo. - ult. 1.000
25 63-75 months ----- ----- ----- ----- 1.000 63 mo. - ult. 1.000
26 75-87 months ----- ----- ----- 1.000 75 mo. - ult. 1.000
27 87-99 months ----- ----- 1.000 87 mo. - ult. 1.000
28 Tail Factor: 1.000 99 mo. - ult. 1.000
29
30 Part 3 Col (1) Col (2) Col (3) Col (4) Col (5) Part 4 Col (1) Col (2) Col (3) Col (4)
31 Incurred Incurred Incurred Incurred A&OE C.I. L+DCCE L+DCCE A&OE Proj. Ultimate
32 Calendar Year Loss D&CC Loss+D&CC A&OE Ratio Accident Year @ 3/31/20 Dev. Factor Factor @ 3/31/20
33 2019 0 0 0 0 0.000 2019 0 1.000 1.050 0
34 2018 0 0 0 0 0.000 2018 0 1.000 1.050 0
35 2017 0 0 0 0 0.000 2017 0 1.000 1.050 0
36 2016 0 0 0 0 0.000 2016 0 1.000 1.050 0
37 2015 0 0 0 0 0.000 2015 0 1.000 1.050 0
38 2014 0 0 0 0 0.000 2014 0 1.000 1.050 0
39 2013 0 0 0 0 0.000 2013 0 1.000 1.050 0
40 2012 0 0 0 0 0.000
41 2011 0 0 0 0 0.000

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 A B C D E F G H I J K L
1 Group Name: enter group name here Exhibit 2B
2 Group NAIC #: enter group # here BI
3 Year Filed: 2020
4
5 Part 1
6 Cum. Case Inc.
7 Loss + ALAE Accident Year
8 as of 2011 2012 2013 2014 2015 2016 2017 2018 2019
9 15 months 0 0 0 0 0 0 0 0 0
10 27 months 0 0 0 0 0 0 0 0
11 39 months 0 0 0 0 0 0 0
12 51 months 0 0 0 0 0 0
13 63 months 0 0 0 0 0
14 75 months 0 0 0 0
15 87 months 0 0 0
16 99 months 0 0
17
18 Part 2 Col (A) Col (B)
19 Development Accident Year Incremental Development Cumulative
20 Factors 2011 2012 2013 2014 2015 2016 2017 2018 LDF Factors LDF
21 15-27 months ----- ----- ----- ----- ----- ----- ----- ----- 1.000 15 mo. - ult. 1.000
22 27-39 months ----- ----- ----- ----- ----- ----- ----- 1.000 27 mo. - ult. 1.000
23 39-51 months ----- ----- ----- ----- ----- ----- 1.000 39 mo. - ult. 1.000
24 51-63 months ----- ----- ----- ----- ----- 1.000 51 mo. - ult. 1.000
25 63-75 months ----- ----- ----- ----- 1.000 63 mo. - ult. 1.000
26 75-87 months ----- ----- ----- 1.000 75 mo. - ult. 1.000
27 87-99 months ----- ----- 1.000 87 mo. - ult. 1.000
28 Tail Factor: 1.000 99 mo. - ult. 1.000
29
30 Part 3 Col (1) Col (2) Col (3) Col (4) Col (5) Part 4 Col (1) Col (2) Col (3) Col (4)
31 Incurred Incurred Incurred Incurred A&OE C.I. L+DCCE L+DCCE A&OE Proj. Ultimate
32 Calendar Year Loss D&CCE Loss+D&CCE A&OE Ratio Accident Year @ 3/31/20 Dev. Factor Factor @ 3/31/20
33 2019 0 0 0 0 0.000 2019 0 1.000 1.050 0
34 2018 0 0 0 0 0.000 2018 0 1.000 1.050 0
35 2017 0 0 0 0 0.000 2017 0 1.000 1.050 0
36 2016 0 0 0 0 0.000 2016 0 1.000 1.050 0
37 2015 0 0 0 0 0.000 2015 0 1.000 1.050 0
38 2014 0 0 0 0 0.000 2014 0 1.000 1.050 0
39 2013 0 0 0 0 0.000 2013 0 1.000 1.050 0
40 2012 0 0 0 0 0.000
41 2011 0 0 0 0 0.000

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 A B C D E F G H I J K L
1 Group Name: enter group name here Exhibit 2B
2 Group NAIC #: enter group # here PD
3 Year Filed: 2020
4
5 Part 1
6 Cum. Case Inc.
7 Loss + ALAE Accident Year
8 as of 2011 2012 2013 2014 2015 2016 2017 2018 2019
9 15 months 0 0 0 0 0 0 0 0 0
10 27 months 0 0 0 0 0 0 0 0 0
11 39 months 0 0 0 0 0 0 0
12 51 months 0 0 0 0 0 0
13
14
15
16
17
18 Part 2 Col (A) Col (B)
19 Development Accident Year Incremental Development Cumulative
20 Factors 2011 2012 2013 2014 2015 2016 2017 2018 LDF Factors LDF
21 15-27 months ----- ----- ----- ----- ----- ----- ----- ----- 1.000 15 mo. - ult. 1.000
22 27-39 months ----- ----- ----- ----- ----- ----- ----- 1.000 27 mo. - ult. 1.000
23 39-51 months ----- ----- ----- ----- ----- ----- 1.000 39 mo. - ult. 1.000
24
25
26
27
28
29
30 Part 3 Col (1) Col (2) Col (3) Col (4) Col (5) Part 4 Col (1) Col (2) Col (3) Col (4)
31 Incurred Incurred Incurred Incurred A&OE C.I. L+DCCE L+DCCE A&OE Proj. Ultimate
32 Calendar Year Loss D&CC Loss+D&CC A&OE Ratio Accident Year @ 3/31/20 Dev. Factor Factor @ 3/31/20
33 2019 0 0 0 0 0.000 2019 0 1.000 1.050 0
34 2018 0 0 0 0 0.000 2018 0 1.000 1.050 0
35 2017 0 0 0 0 0.000 2017 0 1.000 1.050 0
36 2016 0 0 0 0 0.000 2016 0 1.000 1.050 0
37 2015 0 0 0 0 0.000 2015 0 1.000 1.050 0
38 2014 0 0 0 0 0.000 2014 0 1.000 1.050 0
39 2013 0 0 0 0 0.000 2013 0 1.000 1.050 0
40 2012 0 0 0 0 0.000
41 2011 0 0 0 0 0.000

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 A B C D E F G H I J K L
1 Group Name: enter group name here Exhibit 2C
2 Group NAIC #: enter group # here Phys Damage
3 Year Filed: 2020
4
5 Part 1
6 Cum. Case Inc.
7 Loss + ALAE Accident Year
8 as of 2011 2012 2013 2014 2015 2016 2017 2018 2019
9 15 months 0 0 0 0 0 0 0 0 0
10 27 months 0 0 0 0 0 0 0 0
11 39 months 0 0 0 0 0 0 0
12 51 months 0 0 0 0 0 0
13
14
15
16
17
18 Part 2 Col (A) Col (B)
19 Development Accident Year Incremental Development Cumulative
20 Factors 2011 2012 2013 2014 2015 2016 2017 2018 LDF Factors LDF
21 15-27 months ----- ----- ----- ----- ----- ----- ----- ----- 1.000 15 mo. - ult. 1.000
22 27-39 months ----- ----- ----- ----- ----- ----- ----- 1.000 27 mo. - ult. 1.000
23 39-51 months ----- ----- ----- ----- ----- ----- 1.000 39 mo. - ult. 1.000
24
25
26
27
28
29
30 Part 3 Col (1) Col (2) Col (3) Col (4) Col (5) Part 4 Col (1) Col (2) Col (3) Col (4)
31 Incurred Incurred Incurred Incurred A&OE C.I. L+DCCE L+DCCE A&OE Proj. Ultimate
32 Calendar Year Loss D&CC Loss+D&CC A&OE Ratio Accident Year @ 3/31/20 Dev. Factor Factor @ 3/31/20
33 2019 0 0 0 0 0.000 2019 0 1.000 1.050 0
34 2018 0 0 0 0 0.000 2018 0 1.000 1.050 0
35 2017 0 0 0 0 0.000 2017 0 1.000 1.050 0
36 2016 0 0 0 0 0.000 2016 0 1.000 1.050 0
37 2015 0 0 0 0 0.000 2015 0 1.000 1.050 0
38 2014 0 0 0 0 0.000 2014 0 1.000 1.050 0
39 2013 0 0 0 0 0.000 2013 0 1.000 1.050 0
40 2012 0 0 0 0 0.000
41 2011 0 0 0 0 0.000

10/30/2020 Page 126 of 52

 A B C D E F G H I J K L
1 Group Name: enter group name here Exhibit 2
2 Group NAIC #: enter group # here All Coverages
3 Year Filed: 2020
4
5 Part 1
6
7
8
9
10
11
12
13
14
15
16
17
18 Part 2
19
20
21
22
23
24
25
26
27
28
29
30 Part 3 Part 4 Col (4)
31 Proj. Ultimate
32 Accident Year @ 3/31/20
33 2019 0
34 2018 0
35 2017 0
36 2016 0
37 2015 0
38 2014 0
39 2013 0
40
41

10/30/2020 Page 126 of 52

 A B C D E F G
1 Group Name: enter group name here Exhibit 3A
2 Group NAIC #: enter group # here PIP
3 Year Filed: 2020
4
5 Part 1 - Countrywide Part 2 - New Jersey
6 Calendar Year 2019 Col (1) Col (2) Col (3) Col (4)
7 Item 1 Direct Written Premium $0 $0 0
8 Item 2 Direct Earned Premium 0 0.00% 0 0.00%
9 Item 3 Direct Other Acquisition Expense 0 0.00% 0 0.00%
10 Item 4 Direct General Expense 0 0.00% 0 0.00%
11 Item 5 Direct Commission & Brokerage 0 0.00% 0 0.00%
12 Item 6a Expenses subject to Capping (Items 3-5) --- --- 0 0.00%
13 Item 6b Allowable Capped Expense --- --- 0 29.30%
14 Item 6 Additional Allowable Efficiency Expense --- --- 0 29.30%
15 Item 7 Direct Taxes, Licenses & Fees 0 0.00% 0 0.00%
16 Item 8 Direct Prepaid Expenses 0 0.00% 0 0.00%
17 Item 9 Net Catastrophe Reinsurance 0 0.00% 0 0.00%
18 Item 10 LAD Fees Paid --- --- 0 0.00%
19
20 Part 1 - Countrywide Part 2 - New Jersey
21 Calendar Year 2018 Col (1) Col (2) Col (3) Col (4)
22 Item 1 Direct Written Premium $0 $0
23 Item 2 Direct Earned Premium 0 0.00% 0 0.00%
24 Item 3 Direct Other Acquisition Expense 0 0.00% 0 0.00%
25 Item 4 Direct General Expense 0 0.00% 0 0.00%
26 Item 5 Direct Commission & Brokerage 0 0.00% 0 0.00%
27 Item 6a Expenses subject to Capping (Items 3-5) --- --- 0 0.00%
28 Item 6b Allowable Capped Expense --- --- 0 29.30%
29 Item 6 Additional Allowable Efficiency Expense --- --- 0 29.30%
30 Item 7 Direct Taxes, Licenses & Fees 0 0.00% 0 0.00%
31 Item 8 Direct Prepaid Expenses 0 0.00% 0 0.00%
32 Item 9 Net Catastrophe Reinsurance 0 0.00% 0 0.00%
33 Item 10 LAD Fees Paid --- --- 0 0.00%
34
35 Part 1 - Countrywide Part 2 - New Jersey
36 Calendar Year 2017 Col (1) Col (2) Col (3) Col (4)
37 Item 1 Direct Written Premium $0 $0 0
38 Item 2 Direct Earned Premium 0 0 0
39 Item 3 Direct Other Acquisition Expense 0 0.00% 0 0.00%
40 Item 4 Direct General Expense 0 0.00% 0 0.00%
41 Item 5 Direct Commission & Brokerage 0 0.00% 0 0.00%
42 Item 6a Expenses subject to Capping (Items 3-5) --- --- 0 0.00%
43 Item 6b Allowable Capped Expense --- --- 0 29.30%
44 Item 6 Additional Allowable Efficiency Expense --- --- 0 29.30%
45 Item 7 Direct Taxes, Licenses & Fees 0 0.00% 0 0.00%
46 Item 8 Direct Prepaid Expenses 0 0.00% 0 0.00%
47 Item 9 Net Catastrophe Reinsurance 0 0.00% 0 0.00%
48 Item 10 LAD Fees Paid --- --- 0 0.00%
49

10/30/2020 Page 96 of 52
 A B C D E F G
1 Group Name: enter group name here Exhibit 3A
2 Group NAIC #: enter group # here PIP
3 Year Filed: 2020
4
50 Part 1 - Countrywide Part 2 - New Jersey
51 Calendar Year 2016 Col (1) Col (2) Col (3) Col (4)
52 Item 1 Direct Written Premium $0 $0 0
53 Item 2 Direct Earned Premium 0 0 0
54 Item 3 Direct Other Acquisition Expense 0 0.00% 0 0.00%
55 Item 4 Direct General Expense 0 0.00% 0 0.00%
56 Item 5 Direct Commission & Brokerage 0 0.00% 0 0.00%
57 Item 6a Expenses subject to Capping (Items 3-5) --- --- 0 0.00%
58 Item 6b Allowable Capped Expense --- --- 0 29.30%
59 Item 6 Additional Allowable Efficiency Expense --- --- 0 29.30%
60 Item 7 Direct Taxes, Licenses & Fees 0 0.00% 0 0.00%
61 Item 8 Direct Prepaid Expenses 0 0.00% 0 0.00%
62 Item 9 Net Catastrophe Reinsurance 0 0.00% 0 0.00%
63 Item 10 LAD Fees Paid --- --- 0 0.00%
64
65 Part 1 - Countrywide Part 2 - New Jersey
66 Calendar Year 2015 Col (1) Col (2) Col (3) Col (4)
67 Item 1 Direct Written Premium $0 $0 0
68 Item 2 Direct Earned Premium 0 0 0
69 Item 3 Direct Other Acquisition Expense 0 0.00% 0 0.00%
70 Item 4 Direct General Expense 0 0.00% 0 0.00%
71 Item 5 Direct Commission & Brokerage 0 0.00% 0 0.00%
72 Item 6a Expenses subject to Capping (Items 3-5) --- --- 0 0.00%
73 Item 6b Allowable Capped Expense --- --- 0 29.30%
74 Item 6 Additional Allowable Efficiency Expense --- --- 0 29.30%
75 Item 7 Direct Taxes, Licenses & Fees 0 0.00% 0 0.00%
76 Item 8 Direct Prepaid Expenses 0 0.00% 0 0.00%
77 Item 9 Net Catastrophe Reinsurance 0 0.00% 0 0.00%
78 Item 10 LAD Fees Paid --- --- 0 0.00%
79
80 Part 1 - Countrywide Part 2 - New Jersey
81 Calendar Year 2014 Col (1) Col (2) Col (3) Col (4)
82 Item 1 Direct Written Premium $0 $0 0
83 Item 2 Direct Earned Premium 0 0 0
84 Item 3 Direct Other Acquisition Expense 0 0.00% 0 0.00%
85 Item 4 Direct General Expense 0 0.00% 0 0.00%
86 Item 5 Direct Commission & Brokerage 0 0.00% 0 0.00%
87 Item 6a Expenses subject to Capping (Items 3-5) --- --- 0 0.00%
88 Item 6b Allowable Capped Expense --- --- 0 29.30%
89 Item 6 Additional Allowable Efficiency Expense --- --- 0 29.30%
90 Item 7 Direct Taxes, Licenses & Fees 0 0.00% 0 0.00%
91 Item 8 Direct Prepaid Expenses 0 0.00% 0 0.00%
92 Item 9 Net Catastrophe Reinsurance 0 0.00% 0 0.00%
93 Item 10 LAD Fees Paid --- --- 0 0.00%
94

10/30/2020 Page 97 of 52
 A B C D E F G
1 Group Name: enter group name here Exhibit 3A
2 Group NAIC #: enter group # here PIP
3 Year Filed: 2020
4
95 Part 1 - Countrywide Part 2 - New Jersey
96 Calendar Year 2013 Col (1) Col (2) Col (3) Col (4)
97 Item 1 Direct Written Premium $0 $0 0
98 Item 2 Direct Earned Premium 0 0 0
99 Item 3 Direct Other Acquisition Expense 0 0.00% 0 0.00%
100 Item 4 Direct General Expense 0 0.00% 0 0.00%
101 Item 5 Direct Commission & Brokerage 0 0.00% 0 0.00%
102 Item 6a Expenses subject to Capping (Items 3-5) --- --- 0 0.00%
103 Item 6b Allowable Capped Expense --- --- 0 29.30%
104 Item 6 Additional Allowable Efficiency Expense --- --- 0 29.30%
105 Item 7 Direct Taxes, Licenses & Fees 0 0.00% 0 0.00%
106 Item 8 Direct Prepaid Expenses 0 0.00% 0 0.00%
107 Item 9 Net Catastrophe Reinsurance 0 0.00% 0 0.00%
108 Item 10 LAD Fees Paid --- --- 0 0.00%

10/30/2020 Page 98 of 52
 A B C D E F G
1 Group Name: enter group name here Exhibit 3B
2 Group NAIC #: enter group # here Other Liability
3 Year Filed: 2020
4
5 Part 1 - Countrywide Part 2 - New Jersey
6 Calendar Year 2019 Col (1) Col (2) Col (3) Col (4)
7 Item 1 Direct Written Premium $0 $0
8 Item 2 Direct Earned Premium 0 0
9 Item 3 Direct Other Acquisition Expense 0 0.00% 0 0.00%
10 Item 4 Direct General Expense 0 0.00% 0 0.00%
11 Item 5 Direct Commission & Brokerage 0 0.00% 0 0.00%
12 Item 6a Expenses subject to Capping (Items 3-5) --- --- 0 0.00%
13 Item 6b Allowable Capped Expense --- --- 0 29.30%
14 Item 6 Additional Allowable Efficiency Expense --- --- 0 29.30%
15 Item 7 Direct Taxes, Licenses & Fees 0 0.00% 0 0.00%
16 Item 8 Direct Prepaid Expenses 0 0.00% 0 0.00%
17 Item 9 Net Catastrophe Reinsurance 0 0.00% 0 0.00%
18 Item 10 LAD Fees Paid --- --- 0 0.00%
19
20 Part 1 - Countrywide Part 2 - New Jersey
21 Calendar Year 2018 Col (1) Col (2) Col (3) Col (4)
22 Item 1 Direct Written Premium $0 $0
23 Item 2 Direct Earned Premium 0 0
24 Item 3 Direct Other Acquisition Expense 0 0.00% 0 0.00%
25 Item 4 Direct General Expense 0 0.00% 0 0.00%
26 Item 5 Direct Commission & Brokerage 0 0.00% 0 0.00%
27 Item 6a Expenses subject to Capping (Items 3-5) --- --- 0 0.00%
28 Item 6b Allowable Capped Expense --- --- 0 29.30%
29 Item 6 Additional Allowable Efficiency Expense --- --- 0 29.30%
30 Item 7 Direct Taxes, Licenses & Fees 0 0.00% 0 0.00%
31 Item 8 Direct Prepaid Expenses 0 0.00% 0 0.00%
32 Item 9 Net Catastrophe Reinsurance 0 0.00% 0 0.00%
33 Item 10 LAD Fees Paid --- --- 0 0.00%
34
35 Part 1 - Countrywide Part 2 - New Jersey
36 Calendar Year 2017 Col (1) Col (2) Col (3) Col (4)
37 Item 1 Direct Written Premium $0 $0
38 Item 2 Direct Earned Premium 0 0
39 Item 3 Direct Other Acquisition Expense 0 0.00% 0 0.00%
40 Item 4 Direct General Expense 0 0.00% 0 0.00%
41 Item 5 Direct Commission & Brokerage 0 0.00% 0 0.00%
42 Item 6a Expenses subject to Capping (Items 3-5) --- --- 0 0.00%
43 Item 6b Allowable Capped Expense --- --- 0 29.30%
44 Item 6 Additional Allowable Efficiency Expense --- --- 0 29.30%
45 Item 7 Direct Taxes, Licenses & Fees 0 0.00% 0 0.00%
46 Item 8 Direct Prepaid Expenses 0 0.00% 0 0.00%
47 Item 9 Net Catastrophe Reinsurance 0 0.00% 0 0.00%
48 Item 10 LAD Fees Paid --- --- 0 0.00%
49

10/30/2020 Page 96 of 52
 A B C D E F G
1 Group Name: enter group name here Exhibit 3B
2 Group NAIC #: enter group # here Other Liability
3 Year Filed: 2020
4
50 Part 1 - Countrywide Part 2 - New Jersey
51 Calendar Year 2016 Col (1) Col (2) Col (3) Col (4)
52 Item 1 Direct Written Premium $0 $0
53 Item 2 Direct Earned Premium 0 0
54 Item 3 Direct Other Acquisition Expense 0 0.00% 0 0.00%
55 Item 4 Direct General Expense 0 0.00% 0 0.00%
56 Item 5 Direct Commission & Brokerage 0 0.00% 0 0.00%
57 Item 6a Expenses subject to Capping (Items 3-5) --- --- 0 0.00%
58 Item 6b Allowable Capped Expense --- --- 0 29.30%
59 Item 6 Additional Allowable Efficiency Expense --- --- 0 29.30%
60 Item 7 Direct Taxes, Licenses & Fees 0 0.00% 0 0.00%
61 Item 8 Direct Prepaid Expenses 0 0.00% 0 0.00%
62 Item 9 Net Catastrophe Reinsurance 0 0.00% 0 0.00%
63 Item 10 LAD Fees Paid --- --- 0 0.00%
64
65 Part 1 - Countrywide Part 2 - New Jersey
66 Calendar Year 2015 Col (1) Col (2) Col (3) Col (4)
67 Item 1 Direct Written Premium $0 $0
68 Item 2 Direct Earned Premium 0 0
69 Item 3 Direct Other Acquisition Expense 0 0.00% 0 0.00%
70 Item 4 Direct General Expense 0 0.00% 0 0.00%
71 Item 5 Direct Commission & Brokerage 0 0.00% 0 0.00%
72 Item 6a Expenses subject to Capping (Items 3-5) --- --- 0 0.00%
73 Item 6b Allowable Capped Expense --- --- 0 29.30%
74 Item 6 Additional Allowable Efficiency Expense --- --- 0 29.30%
75 Item 7 Direct Taxes, Licenses & Fees 0 0.00% 0 0.00%
76 Item 8 Direct Prepaid Expenses 0 0.00% 0 0.00%
77 Item 9 Net Catastrophe Reinsurance 0 0.00% 0 0.00%
78 Item 10 LAD Fees Paid --- --- 0 0.00%
79
80 Part 1 - Countrywide Part 2 - New Jersey
81 Calendar Year 2014 Col (1) Col (2) Col (3) Col (4)
82 Item 1 Direct Written Premium $0 $0
83 Item 2 Direct Earned Premium 0 0
84 Item 3 Direct Other Acquisition Expense 0 0.00% 0 0.00%
85 Item 4 Direct General Expense 0 0.00% 0 0.00%
86 Item 5 Direct Commission & Brokerage 0 0.00% 0 0.00%
87 Item 6a Expenses subject to Capping (Items 3-5) --- --- 0 0.00%
88 Item 6b Allowable Capped Expense --- --- 0 29.30%
89 Item 6 Additional Allowable Efficiency Expense --- --- 0 29.30%
90 Item 7 Direct Taxes, Licenses & Fees 0 0.00% 0 0.00%
91 Item 8 Direct Prepaid Expenses 0 0.00% 0 0.00%
92 Item 9 Net Catastrophe Reinsurance 0 0.00% 0 0.00%
93 Item 10 LAD Fees Paid --- --- 0 0.00%
94

10/30/2020 Page 97 of 52
 A B C D E F G
1 Group Name: enter group name here Exhibit 3B
2 Group NAIC #: enter group # here Other Liability
3 Year Filed: 2020
4
95 Part 1 - Countrywide Part 2 - New Jersey
96 Calendar Year 2013 Col (1) Col (2) Col (3) Col (4)
97 Item 1 Direct Written Premium $0 $0
98 Item 2 Direct Earned Premium 0 0
99 Item 3 Direct Other Acquisition Expense 0 0.00% 0 0.00%
100 Item 4 Direct General Expense 0 0.00% 0 0.00%
101 Item 5 Direct Commission & Brokerage 0 0.00% 0 0.00%
102 Item 6a Expenses subject to Capping (Items 3-5) --- --- 0 0.00%
103 Item 6b Allowable Capped Expense --- --- 0 29.30%
104 Item 6 Additional Allowable Efficiency Expense --- --- 0 29.30%
105 Item 7 Direct Taxes, Licenses & Fees 0 0.00% 0 0.00%
106 Item 8 Direct Prepaid Expenses 0 0.00% 0 0.00%
107 Item 9 Net Catastrophe Reinsurance 0 0.00% 0 0.00%
108 Item 10 LAD Fees Paid --- --- 0 0.00%

10/30/2020 Page 98 of 52
 A B C D E F G
1 Group Name: enter group name here Exhibit 3C
2 Group NAIC #: enter group # here Phys Damage
3 Year Filed: 2020
4
5 Part 1 - Countrywide Part 2 - New Jersey
6 Calendar Year 2019 Col (1) Col (2) Col (3) Col (4)
7 Item 1 Direct Written Premium $0 $0
8 Item 2 Direct Earned Premium 0 0
9 Item 3 Direct Other Acquisition Expense 0 0.00% 0 0.00%
10 Item 4 Direct General Expense 0 0.00% 0 0.00%
11 Item 5 Direct Commission & Brokerage 0 0.00% 0 0.00%
12 Item 6a Expenses subject to Capping (Items 3-5) --- --- 0 0.00%
13 Item 6b Allowable Capped Expense --- --- 0 30.00%
14 Item 6 Additional Allowable Efficiency Expense --- --- 0 30.00%
15 Item 7 Direct Taxes, Licenses & Fees 0 0.00% 0 0.00%
16 Item 8 Direct Prepaid Expenses 0 0.00% 0 0.00%
17 Item 9 Net Catastrophe Reinsurance 0 0.00% 0 0.00%
18 Item 10 LAD Fees Paid --- --- 0 0.00%
19
20 Part 1 - Countrywide Part 2 - New Jersey
21 Calendar Year 2018 Col (1) Col (2) Col (3) Col (4)
22 Item 1 Direct Written Premium $0 $0
23 Item 2 Direct Earned Premium 0 0
24 Item 3 Direct Other Acquisition Expense 0 0.00% 0 0.00%
25 Item 4 Direct General Expense 0 0.00% 0 0.00%
26 Item 5 Direct Commission & Brokerage 0 0.00% 0 0.00%
27 Item 6a Expenses subject to Capping (Items 3-5) --- --- 0 0.00%
28 Item 6b Allowable Capped Expense --- --- 0 30.00%
29 Item 6 Additional Allowable Efficiency Expense --- --- 0 30.00%
30 Item 7 Direct Taxes, Licenses & Fees 0 0.00% 0 0.00%
31 Item 8 Direct Prepaid Expenses 0 0.00% 0 0.00%
32 Item 9 Net Catastrophe Reinsurance 0 0.00% 0 0.00%
33 Item 10 LAD Fees Paid --- --- 0 0.00%
34
35 Part 1 - Countrywide Part 2 - New Jersey
36 Calendar Year 2017 Col (1) Col (2) Col (3) Col (4)
37 Item 1 Direct Written Premium $0 $0
38 Item 2 Direct Earned Premium 0 0
39 Item 3 Direct Other Acquisition Expense 0 0.00% 0 0.00%
40 Item 4 Direct General Expense 0 0.00% 0 0.00%
41 Item 5 Direct Commission & Brokerage 0 0.00% 0 0.00%
42 Item 6a Expenses subject to Capping (Items 3-5) --- --- 0 0.00%
43 Item 6b Allowable Capped Expense --- --- 0 30.00%
44 Item 6 Additional Allowable Efficiency Expense --- --- 0 30.00%
45 Item 7 Direct Taxes, Licenses & Fees 0 0.00% 0 0.00%
46 Item 8 Direct Prepaid Expenses 0 0.00% 0 0.00%
47 Item 9 Net Catastrophe Reinsurance 0 0.00% 0 0.00%
48 Item 10 LAD Fees Paid --- --- 0 0.00%
49

10/30/2020 Page 96 of 52
 A B C D E F G
1 Group Name: enter group name here Exhibit 3C
2 Group NAIC #: enter group # here Phys Damage
3 Year Filed: 2020
4
50 Part 1 - Countrywide Part 2 - New Jersey
51 Calendar Year 2016 Col (1) Col (2) Col (3) Col (4)
52 Item 1 Direct Written Premium $0 $0
53 Item 2 Direct Earned Premium 0 0
54 Item 3 Direct Other Acquisition Expense 0 0.00% 0 0.00%
55 Item 4 Direct General Expense 0 0.00% 0 0.00%
56 Item 5 Direct Commission & Brokerage 0 0.00% 0 0.00%
57 Item 6a Expenses subject to Capping (Items 3-5) --- --- 0 0.00%
58 Item 6b Allowable Capped Expense --- --- 0 30.00%
59 Item 6 Additional Allowable Efficiency Expense --- --- 0 30.00%
60 Item 7 Direct Taxes, Licenses & Fees 0 0.00% 0 0.00%
61 Item 8 Direct Prepaid Expenses 0 0.00% 0 0.00%
62 Item 9 Net Catastrophe Reinsurance 0 0.00% 0 0.00%
63 Item 10 LAD Fees Paid --- --- 0 0.00%
64
65 Part 1 - Countrywide Part 2 - New Jersey
66 Calendar Year 2015 Col (1) Col (2) Col (3) Col (4)
67 Item 1 Direct Written Premium $0 $0
68 Item 2 Direct Earned Premium 0 0
69 Item 3 Direct Other Acquisition Expense 0 0.00% 0 0.00%
70 Item 4 Direct General Expense 0 0.00% 0 0.00%
71 Item 5 Direct Commission & Brokerage 0 0.00% 0 0.00%
72 Item 6a Expenses subject to Capping (Items 3-5) --- --- 0 0.00%
73 Item 6b Allowable Capped Expense --- --- 0 30.00%
74 Item 6 Additional Allowable Efficiency Expense --- --- 0 30.00%
75 Item 7 Direct Taxes, Licenses & Fees 0 0.00% 0 0.00%
76 Item 8 Direct Prepaid Expenses 0 0.00% 0 0.00%
77 Item 9 Net Catastrophe Reinsurance 0 0.00% 0 0.00%
78 Item 10 LAD Fees Paid --- --- 0 0.00%
79
80 Part 1 - Countrywide Part 2 - New Jersey
81 Calendar Year 2014 Col (1) Col (2) Col (3) Col (4)
82 Item 1 Direct Written Premium $0 $0
83 Item 2 Direct Earned Premium 0 0
84 Item 3 Direct Other Acquisition Expense 0 0.00% 0 0.00%
85 Item 4 Direct General Expense 0 0.00% 0 0.00%
86 Item 5 Direct Commission & Brokerage 0 0.00% 0 0.00%
87 Item 6a Expenses subject to Capping (Items 3-5) --- --- 0 0.00%
88 Item 6b Allowable Capped Expense --- --- 0 30.00%
89 Item 6 Additional Allowable Efficiency Expense --- --- 0 30.00%
90 Item 7 Direct Taxes, Licenses & Fees 0 0.00% 0 0.00%
91 Item 8 Direct Prepaid Expenses 0 0.00% 0 0.00%
92 Item 9 Net Catastrophe Reinsurance 0 0.00% 0 0.00%
93 Item 10 LAD Fees Paid --- --- 0 0.00%
94

10/30/2020 Page 97 of 52
 A B C D E F G
1 Group Name: enter group name here Exhibit 3C
2 Group NAIC #: enter group # here Phys Damage
3 Year Filed: 2020
4
95 Part 1 - Countrywide Part 2 - New Jersey
96 Calendar Year 2013 Col (1) Col (2) Col (3) Col (4)
97 Item 1 Direct Written Premium $0 $0
98 Item 2 Direct Earned Premium 0 0
99 Item 3 Direct Other Acquisition Expense 0 0.00% 0 0.00%
100 Item 4 Direct General Expense 0 0.00% 0 0.00%
101 Item 5 Direct Commission & Brokerage 0 0.00% 0 0.00%
102 Item 6a Expenses subject to Capping (Items 3-5) --- --- 0 0.00%
103 Item 6b Allowable Capped Expense --- --- 0 30.00%
104 Item 6 Additional Allowable Efficiency Expense --- --- 0 30.00%
105 Item 7 Direct Taxes, Licenses & Fees 0 0.00% 0 0.00%
106 Item 8 Direct Prepaid Expenses 0 0.00% 0 0.00%
107 Item 9 Net Catastrophe Reinsurance 0 0.00% 0 0.00%
108 Item 10 LAD Fees Paid --- --- 0 0.00%

10/30/2020 Page 98 of 52
 A B C D E F G
5 Part 1 - Countrywide Part 2 - New Jersey
6 Calendar Year 2019 Col (1) Col (3)
7 Item 1 Direct Written Premium $0 $0
8 Item 2 Direct Earned Premium 0 0
9 Item 3 Direct Other Acquisition Expense 0 0
10 Item 4 Direct General Expense 0 0
11 Item 5 Direct Commission & Brokerage 0 0
12 Item 6a Expenses subject to Capping (Items 3-5) --- 0
13 Item 6b Allowable Capped Expense --- 0
14 Item 6 Additional Allowable Efficiency Expense --- 0
15 Item 7 Direct Taxes, Licenses & Fees 0 0
16 Item 8 Direct Prepaid Expenses 0 0
17 Item 9 Net Catastrophe Reinsurance 0 0
18 Item 10 LAD Fees Paid --- 0
19
20 Part 1 - Countrywide Part 2 - New Jersey
21 Calendar Year 2018 Col (1) Col (3)
22 Item 1 Direct Written Premium $0 $0
23 Item 2 Direct Earned Premium 0 0
24 Item 3 Direct Other Acquisition Expense 0 0
25 Item 4 Direct General Expense 0 0
26 Item 5 Direct Commission & Brokerage 0 0
27 Item 6a Expenses subject to Capping (Items 3-5) --- 0
28 Item 6b Allowable Capped Expense --- 0
29 Item 6 Additional Allowable Efficiency Expense --- 0
30 Item 7 Direct Taxes, Licenses & Fees 0 0
31 Item 8 Direct Prepaid Expenses 0 0
32 Item 9 Net Catastrophe Reinsurance 0 0
33 Item 10 LAD Fees Paid --- 0
34
35 Part 1 - Countrywide Part 2 - New Jersey
36 Calendar Year 2017 Col (1) Col (3)
37 Item 1 Direct Written Premium $0 $0
38 Item 2 Direct Earned Premium 0 0
39 Item 3 Direct Other Acquisition Expense 0 0
40 Item 4 Direct General Expense 0 0
41 Item 5 Direct Commission & Brokerage 0 0
42 Item 6a Expenses subject to Capping (Items 3-5) --- 0
43 Item 6b Allowable Capped Expense --- 0
44 Item 6 Additional Allowable Efficiency Expense --- 0
45 Item 7 Direct Taxes, Licenses & Fees 0 0
46 Item 8 Direct Prepaid Expenses 0 0
47 Item 9 Net Catastrophe Reinsurance 0 0
48 Item 10 LAD Fees Paid --- 0
49

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 A B C D E F G
50 Part 1 - Countrywide Part 2 - New Jersey
51 Calendar Year 2016 Col (1) Col (3)
52 Item 1 Direct Written Premium $0 $0
53 Item 2 Direct Earned Premium 0 0
54 Item 3 Direct Other Acquisition Expense 0 0
55 Item 4 Direct General Expense 0 0
56 Item 5 Direct Commission & Brokerage 0 0
57 Item 6a Expenses subject to Capping (Items 3-5) --- 0
58 Item 6b Allowable Capped Expense --- 0
59 Item 6 Additional Allowable Efficiency Expense --- 0
60 Item 7 Direct Taxes, Licenses & Fees 0 0
61 Item 8 Direct Prepaid Expenses 0 0
62 Item 9 Net Catastrophe Reinsurance 0 0
63 Item 10 LAD Fees Paid --- 0
64
65 Part 1 - Countrywide Part 2 - New Jersey
66 Calendar Year 2015 Col (1) Col (3)
67 Item 1 Direct Written Premium $0 $0
68 Item 2 Direct Earned Premium 0 0
69 Item 3 Direct Other Acquisition Expense 0 0
70 Item 4 Direct General Expense 0 0
71 Item 5 Direct Commission & Brokerage 0 0
72 Item 6a Expenses subject to Capping (Items 3-5) --- 0
73 Item 6b Allowable Capped Expense --- 0
74 Item 6 Additional Allowable Efficiency Expense --- 0
75 Item 7 Direct Taxes, Licenses & Fees 0 0
76 Item 8 Direct Prepaid Expenses 0 0
77 Item 9 Net Catastrophe Reinsurance 0 0
78 Item 10 LAD Fees Paid --- 0
79
80 Part 1 - Countrywide Part 2 - New Jersey
81 Calendar Year 2014 Col (1) Col (3)
82 Item 1 Direct Written Premium $0 $0
83 Item 2 Direct Earned Premium 0 0
84 Item 3 Direct Other Acquisition Expense 0 0
85 Item 4 Direct General Expense 0 0
86 Item 5 Direct Commission & Brokerage 0 0
87 Item 6a Expenses subject to Capping (Items 3-5) --- 0
88 Item 6b Allowable Capped Expense --- 0
89 Item 6 Additional Allowable Efficiency Expense --- 0
90 Item 7 Direct Taxes, Licenses & Fees 0 0
91 Item 8 Direct Prepaid Expenses 0 0
92 Item 9 Net Catastrophe Reinsurance 0 0
93 Item 10 LAD Fees Paid --- 0
94

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 A B C D E F G
95 Part 1 - Countrywide Part 2 - New Jersey
96 Calendar Year 2013 Col (1) Col (3)
97 Item 1 Direct Written Premium $0 $0
98 Item 2 Direct Earned Premium 0 0
99 Item 3 Direct Other Acquisition Expense 0 0
100 Item 4 Direct General Expense 0 0
101 Item 5 Direct Commission & Brokerage 0 0
102 Item 6a Expenses subject to Capping (Items 3-5) --- 0
103 Item 6b Allowable Capped Expense --- 0
104 Item 6 Additional Allowable Efficiency Expense --- 0
105 Item 7 Direct Taxes, Licenses & Fees 0 0
106 Item 8 Direct Prepaid Expenses 0 0
107 Item 9 Net Catastrophe Reinsurance 0 0
108 Item 10 LAD Fees Paid --- 0

10/30/2020 Page 98 of 52
 A B C D E F G H I J K
1 Group Name: enter group name here Exhibit 4
2 Group NAIC #: enter group # here
3 Year Filed: 2020
4
5 Calendar Year
6 Investment Income 2013 2014 2015 2016 2017 2018 2019 7-Yr Total
7 Item 1 Interest, Dividends & Real Estate Income 0 0 0 0 0 0 0 0
8 Item 2.1 Investment Expense Incurred 0 0 0 0 0 0 0 0
9 Item 2.2 Depreciation on Real Estate 0 0 0 0 0 0 0 0
10 Item 2.3 Unaffiliated Preferred Stock 0 0 0 0 0 0 0 0
11 Item 2.4 Affiliated Preferred Stock 0 0 0 0 0 0 0 0
12 Item 2.5 Unaffiliated Common Stock 0 0 0 0 0 0 0 0
13 Item 2.6 Affiliated Common Stock 0 0 0 0 0 0 0 0
14 Item 2.7 Derivative Instruments 0 0 0 0 0 0 0 0
15 Item 2.8 Other Invested Assets 0 0 0 0 0 0 0 0
16 Item 2.9 Real Estate for Co's Own Occupancy 0 0 0 0 0 0 0 0
17 Item 2 Total Deductions 0 0 0 0 0 0 0 0
18 Item 3 Net Investment Income [Item 1 - Item 2] 0 0 0 0 0 0 0 0
19
20 Calendar Year
21 Invested Assets 2012 2013 2014 2015 2016 2017 2018 2019 7-Yr Total
22 Item 4.1 Bonds Acquired 0 0 0 0 0 0 0 0 0
23 Item 4.2 Mortgage Loans on RE 0 0 0 0 0 0 0 0 0
24 Item 4.3 Real Estate 0 0 0 0 0 0 0 0 0
25 Item 4.4 Collateral Loans 0 0 0 0 0 0 0 0 0
26 Item 4.5 Cash on Hand/Deposit 0 0 0 0 0 0 0 0 0
27 Item 4 Ending Invested Assets 0 0 0 0 0 0 0 0 0
28 Item 5 Average Invested Assets [Avg. Item 4] 0 0 0 0 0 0 0 0
29
30 Calendar Year
31 Rate of Return 2013 2014 2015 2016 2017 2018 2019 7-Yr Total
32 Item 6 Net Investment Income [Item 3] 0 0 0 0 0 0 0 0
33 Item 7 Average Invested Assets [Item 5] 0 0 0 0 0 0 0 0
34 Item 8 Pre-Tax Rate of Return [Item 6 / Item 7] 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

10/30/2020 Page 97 of 52
 A B C D E F G H I
1 Group Name: enter group name here Exhibit 5A
2 Group NAIC #: enter group # here PIP
3 Year Filed: 2020
4
5
6 0 2013 2014 2015 2016 2017 2018 2019
7 Item 1 Agents Balances 0 0 0 0 0 0 0
8 Item 2 Unearned Premium Reserve 0 0 0 0 0 0 0
9 Item 3 Agents Balance Ratio [Item 1 / Item 2] 0.000 0.000 0.000 0.000 0.000 0.000 0.000
10 Item 4 Direct Prepaid Expenses - NJ [Exhibit 4] 0 0 0 0 0 0 0
11 Item 5 Direct Net Written Premium - NJ [Exhibit 4] 0 0 0 0 0 0 0
12 Item 6 Prepaid Expense Ratio [Item 4 / Item 5] 0.000 0.000 0.000 0.000 0.000 0.000 0.000
13 Item 7a Direct Unearned Premium Reserve - Beginning [Exhibit 1] 0 0 0 0 0 0 0
14 Item 7b Direct Unearned Premium Reserve - Ending [Exhibit 1] 0 0 0 0 0 0 0
15 Item 7 Average Unearned Premium Reserve [(Item 7a + Item 7b) / 2] 0 0 0 0 0 0 0
16 Item 8 Investable Unearned Premium [Item 7 * (1 - Item 3 - Item 6)] 0 0 0 0 0 0 0
17 Item 9a Direct Unpaid Loss - Beginning [Exhibit 1] 0 0 0 0 0 0 0
18 Item 9b Direct Unpaid Loss - Ending [Exhibit 1] 0 0 0 0 0 0 0
19 Item 9 Average Loss Reserve [(Item 9a + Item 9b) / 2] 0 0 0 0 0 0 0
20 Item 10a Direct Unpaid D&CCE - Beginning [Exhibit 1, Col (6), Item 3] 0 0 0 0 0 0 0
21 Item 10b Direct Unpaid D&CCE - Ending [Exhibit 1, Col (6), Item 3] 0 0 0 0 0 0 0
22 Item 10 Average D&CCE Reserve [(Item 10a + Item 10b) / 2] 0 0 0 0 0 0 0
23 Item 11 A&OE Ratio [Exhibit 2, Part 4, Col (4] 1.050 1.050 1.050 1.050 1.050 1.050 1.050
24 Item 12 Average Loss + LAE Reserve [(Item 9 + Item 10) * Item 11] 0 0 0 0 0 0 0
25 Item 13 Total Reserve [Item 8 + Item 12] 0 0 0 0 0 0 0
26 Item 14 Pre-Tax Rate of Return [Exhibit 4, Item 8, 3-Yr Total] 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
27 Item 15 Actual Investment Income Earned [Item 13 * Item 14] 0 0 0 0 0 0 0

10/30/2020 Page 97 of 52
 A B C D E F G H I
1 Group Name: enter group name here Exhibit 5B
2 Group NAIC #: enter group # here Other Liability
3 Year Filed: 2020
4
5
6 2013 2014 2015 2016 2017 2018 2019
7 Item 1 Agents Balances 0 0 0 0 0 0 0
8 Item 2 Unearned Premium Reserve 0 0 0 0 0 0 0
9 Item 3 Agents Balance Ratio [Item 1 / Item 2] 0.000 0.000 0.000 0.000 0.000 0.000 0.000
10 Item 4 Direct Prepaid Expenses - NJ [Exhibit 4] 0 0 0 0 0 0 0
11 Item 5 Direct Net Written Premium - NJ [Exhibit 4] 0 0 0 0 0 0 0
12 Item 6 Prepaid Expense Ratio [Item 4 / Item 5] 0.000 0.000 0.000 0.000 0.000 0.000 0.000
13 Item 7a Direct Unearned Premium Reserve - Beginning [Exhibit 1] 0 0 0 0 0 0 0
14 Item 7b Direct Unearned Premium Reserve - Ending [Exhibit 1] 0 0 0 0 0 0 0
15 Item 7 Average Unearned Premium Reserve [(Item 7a + Item 7b) / 2] 0 0 0 0 0 0 0
16 Item 8 Investable Unearned Premium [Item 7 * (1 - Item 3 - Item 6)] 0 0 0 0 0 0 0
17 Item 9a Direct Unpaid Loss - Beginning [Exhibit 1] 0 0 0 0 0 0 0
18 Item 9b Direct Unpaid Loss - Ending [Exhibit 1] 0 0 0 0 0 0 0
19 Item 9 Average Loss Reserve [(Item 9a + Item 9b) / 2] 0 0 0 0 0 0 0
20 Item 10a Direct Unpaid D&CCE - Beginning [Exhibit 1, Col (6), Item 3] 0 0 0 0 0 0 0
21 Item 10b Direct Unpaid D&CCE - Ending [Exhibit 1, Col (6), Item 3] 0 0 0 0 0 0 0
22 Item 10 Average D&CCE Reserve [(Item 10a + Item 10b) / 2] 0 0 0 0 0 0 0
23 Item 11 A&OE Ratio [Exhibit 2, Part 4, Col (4] 1.050 1.050 1.050 1.050 1.050 1.050 1.050
24 Item 12 Average Loss + LAE Reserve [(Item 9 + Item 10) * Item 11] 0 0 0 0 0 0 0
25 Item 13 Total Reserve [Item 8 + Item 12] 0 0 0 0 0 0 0
26 Item 14 Pre-Tax Rate of Return [Exhibit 4, Item 8, 3-Yr Total] 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
27 Item 15 Actual Investment Income Earned [Item 13 * Item 14] 0 0 0 0 0 0 0

10/30/2020 Page 97 of 52
 A B C D E F G H I
1 Group Name: enter group name here Exhibit 5C
2 Group NAIC #: enter group # here Phys Damage
3 Year Filed: 2020
4
5
6 0 2013 2014 2015 2016 2017 2018 2019
7 Item 1 Agents Balances 0 0 0 0 0 0 0
8 Item 2 Unearned Premium Reserve 0 0 0 0 0 0 0
9 Item 3 Agents Balance Ratio [Item 1 / Item 2] 0.000 0.000 0.000 0.000 0.000 0.000 0.000
10 Item 4 Direct Prepaid Expenses - NJ [Exhibit 4] 0 0 0 0 0 0 0
11 Item 5 Direct Net Written Premium - NJ [Exhibit 4] 0 0 0 0 0 0 0
12 Item 6 Prepaid Expense Ratio [Item 4 / Item 5] 0.000 0.000 0.000 0.000 0.000 0.000 0.000
13 Item 7a Direct Unearned Premium Reserve - Beginning [Exhibit 1] 0 0 0 0 0 0 0
14 Item 7b Direct Unearned Premium Reserve - Ending [Exhibit 1] 0 0 0 0 0 0 0
15 Item 7 Average Unearned Premium Reserve [(Item 7a + Item 7b) / 2] 0 0 0 0 0 0 0
16 Item 8 Investable Unearned Premium [Item 7 * (1 - Item 3 - Item 6)] 0 0 0 0 0 0 0
17 Item 9a Direct Unpaid Loss - Beginning [Exhibit 1] 0 0 0 0 0 0 0
18 Item 9b Direct Unpaid Loss - Ending [Exhibit 1] 0 0 0 0 0 0 0
19 Item 9 Average Loss Reserve [(Item 9a + Item 9b) / 2] 0 0 0 0 0 0 0
20 Item 10a Direct Unpaid D&CCE - Beginning [Exhibit 1, Col (6), Item 3] 0 0 0 0 0 0 0
21 Item 10b Direct Unpaid D&CCE - Ending [Exhibit 1, Col (6), Item 3] 0 0 0 0 0 0 0
22 Item 10 Average D&CCE Reserve [(Item 10a + Item 10b) / 2] 0 0 0 0 0 0 0
23 Item 11 A&OE Ratio [Exhibit 2, Part 4, Col (4] 1.050 1.050 1.050 1.050 1.050 1.050 1.050
24 Item 12 Average Loss + LAE Reserve [(Item 9 + Item 10) * Item 11] 0 0 0 0 0 0 0
25 Item 13 Total Reserve [Item 8 + Item 12] 0 0 0 0 0 0 0
26 Item 14 Pre-Tax Rate of Return [Exhibit 4, Item 8, 3-Yr Total] 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
27 Item 15 Actual Investment Income Earned [Item 13 * Item 14] 0 0 0 0 0 0 0

10/30/2020 Page 97 of 52
 A B C D E F G H I
1 Group Name: enter group name here Exhibit 5
2 Group NAIC #: enter group # here TOTAL
3 Year Filed: 2020
4
5
6 0 2013 2014 2015 2016 2017 2018 2019
7 Item 1 Agents Balances
8 Item 2 Unearned Premium Reserve
9 Item 3 Agents Balance Ratio [Item 1 / Item 2]
10 Item 4 Direct Prepaid Expenses - NJ [Exhibit 4]
11 Item 5 Direct Net Written Premium - NJ [Exhibit 4]
12 Item 6 Prepaid Expense Ratio [Item 4 / Item 5]
13 Item 7a Direct Unearned Premium Reserve - Beginning [Exhibit 1]
14 Item 7b Direct Unearned Premium Reserve - Ending [Exhibit 1]
15 Item 7 Average Unearned Premium Reserve [(Item 7a + Item 7b) / 2]
16 Item 8 Investable Unearned Premium [Item 7 * (1 - Item 3 - Item 6)]
17 Item 9a Direct Unpaid Loss - Beginning [Exhibit 1]
18 Item 9b Direct Unpaid Loss - Ending [Exhibit 1]
19 Item 9 Average Loss Reserve [(Item 9a + Item 9b) / 2]
20 Item 10a Direct Unpaid D&CCE - Beginning [Exhibit 1, Col (6), Item 3]
21 Item 10b Direct Unpaid D&CCE - Ending [Exhibit 1, Col (6), Item 3]
22 Item 10 Average D&CCE Reserve [(Item 10a + Item 10b) / 2]
23 Item 11 A&OE Ratio [Exhibit 2, Part 4, Col (4]
24 Item 12 Average Loss + LAE Reserve [(Item 9 + Item 10) * Item 11]
25 Item 13 Total Reserve [Item 8 + Item 12]
26 Item 14 Pre-Tax Rate of Return [Exhibit 4, Item 8, 3-Yr Total]
27 Item 15 Actual Investment Income Earned [Item 13 * Item 14] 0 0 0 0 0 0 0

10/30/2020 Page 97 of 52
 A B C D E F G H I J
1 Group Name: enter group name here Exhibit 6
2 Group NAIC #: enter group # here Sheet 1
3 Year Filed: 2020
4
5
6 Calendar Year
7 2020 2019 2018 2017 2016 2015 2014 2013
8 Item 1 Excess Profit Paid 0 0 0 0 0 0 0 0
9
10
11 Carryforward Used Calendar Year Excess Profit Paid
12 for Accident Year 2020 2019 2018 2017 2016 2015 2014 2013
13 Item 2.1 2019 0 0 0 0 0 0 0 0
14 Item 2.2 2018 0 0 0 0 0 0 0 0
15 Item 2.3 2017 0 0 0 0 0 0 0 0
16 Item 2.4 2016 0 0 0 0 0 0 0 0
17 Item 2.5 2015 0 0 0 0 0 0 0 0
18 Item 2.6 2014 0 0 0 0 0 0 0 0
19 Item 2.7 2013 0 0 0 0 0 0 0 0
20 Item 2.8 2012 XXX 0 0 0 0 0 0 0
21 Item 2.9 2011 XXX XXX 0 0 0 0 0 0
22 Item 2.10 2010 XXX XXX XXX 0 0 0 0 0
23 Item 2.11 2009 XXX XXX XXX XXX 0 0 0 0
24 Item 2.12 2008 XXX XXX XXX XXX XXX 0 0 0
25 Item 2.13 2007 XXX XXX XXX XXX XXX XXX 0 0
26 Item 2.14 2006 XXX XXX XXX XXX XXX XXX XXX 0
27 Item 2.15 2005 XXX XXX XXX XXX XXX XXX XXX XXX
28 Item 2.16 2004 XXX XXX XXX XXX XXX XXX XXX XXX
29 Item 2.17 2003 XXX XXX XXX XXX XXX XXX XXX XXX
30 Item 2.18 2002 XXX XXX XXX XXX XXX XXX XXX XXX
31 Item 2.19 2001 XXX XXX XXX XXX XXX XXX XXX XXX
32 Item 2.20 2000 XXX XXX XXX XXX XXX XXX XXX XXX
33 Item 2.21 1999 XXX XXX XXX XXX XXX XXX XXX XXX
34 Item 2.22 1998 XXX XXX XXX XXX XXX XXX XXX XXX
35 Item 2.23 1997 XXX XXX XXX XXX XXX XXX XXX XXX
36
37 Item 2 Total Carryforward Used 0 0 0 0 0 0 0 0
38
39 Item 3 Carryforward Unused 0 0 0 0 0 0 0 0

10/30/2020 Page 38 of 52
 K L M N O P Q R S T
1 Group Name: enter group name here Exhibit 6
2 Group NAIC #: enter group # here Sheet 2
3 Year Filed: 2020
4
5
6 Calendar Year
7 2012 2011 2010 2009 2008 2007 2006 2005 2004 Total
8 0 0 0 0 0 0 0 0 0 0
9
10
11 Calendar Year Excess Profit Paid
12 2012 2011 2010 2009 2008 2007 2006 2005 2004 Total
13 0 0 0 0 0 0 0 0 0 0
14 0 0 0 0 0 0 0 0 0 0
15 0 0 0 0 0 0 0 0 0 0
16 0 0 0 0 0 0 0 0 0 0
17 0 0 0 0 0 0 0 0 0 0
18 0 0 0 0 0 0 0 0 0 0
19 0 0 0 0 0 0 0 0 0 0
20 0 0 0 0 0 0 0 0 0 0
21 0 0 0 0 0 0 0 0 0 0
22 0 0 0 0 0 0 0 0 0 0
23 0 0 0 0 0 0 0 0 0 0
24 0 0 0 0 0 0 0 0 0 0
25 0 0 0 0 0 0 0 0 0 0
26 0 0 0 0 0 0 0 0 0 0
27 0 0 0 0 0 0 0 0 0 0
28 XXX 0 0 0 0 0 0 0 0 0
29 XXX XXX 0 0 0 0 0 0 0 0
30 XXX XXX XXX 0 0 0 0 0 0 0
31 XXX XXX XXX XXX 0 0 0 0 0 0
32 XXX XXX XXX XXX XXX 0 0 0 0 0
33 XXX XXX XXX XXX XXX XXX 0 0 0 0
34 XXX XXX XXX XXX XXX XXX XXX 0 0 0
35 XXX XXX XXX XXX XXX XXX XXX XXX 0 0
36
37 0 0 0 0 0 0 0 0 0 0
38
39 0 0 0 0 0 0 0 0 0 0

10/30/2020 Page 39 of 52
 A B C D E F G H I J
1 Group Name: enter group name here Exhibit 7
2 Group NAIC #: enter group # here Sheet 1
3 Year Filed: 2020
4
5
6 Calendar Year
7 2020 2019 2018 2017 2016 2015 2014 2013
8 Item 1 Extraordinary Loss Inc. XXX #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!
9
10
11 Carryforward Used Calendar Year Extraordinary Loss Incurred
12 for Accident Year 2020 2019 2018 2017 2016 2015 2014 2013
13 Item 2.1 2019 XXX 0 0 0 0 0 0 0
14 Item 2.2 2018 XXX 0 0 0 0 0 0 0
15 Item 2.3 2017 XXX 0 0 0 0 0 0 0
16 Item 2.4 2016 XXX 0 0 0 0 0 0 0
17 Item 2.5 2015 XXX 0 0 0 0 0 0 0
18 Item 2.6 2014 XXX 0 0 0 0 0 0 0
19 Item 2.7 2013 XXX 0 0 0 0 0 0 0
20 Item 2.8 2012 XXX 0 0 0 0 0 0 0
21 Item 2.9 2011 XXX XXX 0 0 0 0 0 0
22 Item 2.10 2010 XXX XXX XXX 0 0 0 0 0
23 Item 2.11 2009 XXX XXX XXX XXX 0 0 0 0
24 Item 2.12 2008 XXX XXX XXX XXX XXX 0 0 0
25 Item 2.13 2007 XXX XXX XXX XXX XXX XXX 0 0
26 Item 2.14 2006 XXX XXX XXX XXX XXX XXX XXX 0
27 Item 2.15 2005 XXX XXX XXX XXX XXX XXX XXX XXX
28 Item 2.16 2004 XXX XXX XXX XXX XXX XXX XXX XXX
29 Item 2.17 2003 XXX XXX XXX XXX XXX XXX XXX XXX
30 Item 2.18 2002 XXX XXX XXX XXX XXX XXX XXX XXX
31 Item 2.19 2001 XXX XXX XXX XXX XXX XXX XXX XXX
32 Item 2.20 2000 XXX XXX XXX XXX XXX XXX XXX XXX
33 Item 2.21 1999 XXX XXX XXX XXX XXX XXX XXX XXX
34 Item 2.22 1998 XXX XXX XXX XXX XXX XXX XXX XXX
35 Item 2.23 1997 XXX XXX XXX XXX XXX XXX XXX XXX
36
37 Item 2 Total Carryforward Used XXX 0 0 0 0 0 0 0
38
39 Item 3 Carryforward Unused XXX #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!

10/30/2020 Page 40 of 52
 K L M N O P Q R S T
1 Group Name: enter group name here Exhibit 7
2 Group NAIC #: enter group # here Sheet 2
3 Year Filed: 2020
4
5
6 Calendar Year
7 2012 2011 2010 2009 2008 2007 2006 2005 2004 Total
8 0 0 0 0 0 0 0 0 0 #VALUE!
9
10
11 Calendar Year Extraordinary Loss Incurred
12 2012 2011 2010 2009 2008 2007 2006 2005 2004 Total
13 0 0 0 0 0 0 0 0 0 0
14 0 0 0 0 0 0 0 0 0 0
15 0 0 0 0 0 0 0 0 0 0
16 0 0 0 0 0 0 0 0 0 0
17 0 0 0 0 0 0 0 0 0 0
18 0 0 0 0 0 0 0 0 0 0
19 0 0 0 0 0 0 0 0 0 0
20 0 0 0 0 0 0 0 0 0 0
21 0 0 0 0 0 0 0 0 0 0
22 0 0 0 0 0 0 0 0 0 0
23 0 0 0 0 0 0 0 0 0 0
24 0 0 0 0 0 0 0 0 0 0
25 0 0 0 0 0 0 0 0 0 0
26 0 0 0 0 0 0 0 0 0 0
27 0 0 0 0 0 0 0 0 0 0
28 XXX 0 0 0 0 0 0 0 0 0
29 XXX XXX 0 0 0 0 0 0 0 0
30 XXX XXX XXX 0 0 0 0 0 0 0
31 XXX XXX XXX XXX 0 0 0 0 0 0
32 XXX XXX XXX XXX XXX 0 0 0 0 0
33 XXX XXX XXX XXX XXX XXX 0 0 0 0
34 XXX XXX XXX XXX XXX XXX XXX 0 0 0
35 XXX XXX XXX XXX XXX XXX XXX XXX 0 0
36
37 0 0 0 0 0 0 0 0 0 0
38
39 0 0 0 0 0 0 0 0 0 #VALUE!

10/30/2020 Page 41 of 52
 A B C D E F G H I J
1 Group Name: enter group name here Exhibit 8
2 Group NAIC #: enter group # here Sheet 1
3 Year Filed: 2020
4
5
6 Calendar Year
7 2020 2019 2018 2017 2016 2015 2014 2013
8 Item 1 Reinvestment into NJ 0 0 0 0 0 0 0 0
9
10
11 Carryforward Used Calendar Year Reinvestment
12 for Accident Year 2020 2019 2018 2017 2016 2015 2014 2013
13 Item 2.1 2019 0 0 0 0 0 0 0 0
14 Item 2.2 2018 0 0 0 0 0 0 0 0
15 Item 2.3 2017 0 0 0 0 0 0 0 0
16 Item 2.4 2016 0 0 0 0 0 0 0 0
17 Item 2.5 2015 0 0 0 0 0 0 0 0
18 Item 2.6 2014 0 0 0 0 0 0 0 0
19 Item 2.7 2013 0 0 0 0 0 0 0 0
20 Item 2.8 2012 XXX 0 0 0 0 0 0 0
21 Item 2.9 2011 XXX XXX 0 0 0 0 0 0
22 Item 2.10 2010 XXX XXX XXX 0 0 0 0 0
23 Item 2.11 2009 XXX XXX XXX XXX 0 0 0 0
24 Item 2.12 2008 XXX XXX XXX XXX XXX 0 0 0
25 Item 2.13 2007 XXX XXX XXX XXX XXX XXX 0 0
26 Item 2.14 2006 XXX XXX XXX XXX XXX XXX XXX 0
27 Item 2.15 2005 XXX XXX XXX XXX XXX XXX XXX XXX
28 Item 2.16 2004 XXX XXX XXX XXX XXX XXX XXX XXX
29 Item 2.17 2003 XXX XXX XXX XXX XXX XXX XXX XXX
30 Item 2.18 2002 XXX XXX XXX XXX XXX XXX XXX XXX
31 Item 2.19 2001 XXX XXX XXX XXX XXX XXX XXX XXX
32 Item 2.20 2000 XXX XXX XXX XXX XXX XXX XXX XXX
33 Item 2.21 1999 XXX XXX XXX XXX XXX XXX XXX XXX
34 Item 2.22 1998 XXX XXX XXX XXX XXX XXX XXX XXX
35 Item 2.23 1997 XXX XXX XXX XXX XXX XXX XXX XXX
36
37 Item 2 Total Carryforward Used 0 0 0 0 0 0 0 0
38
39 Item 3 Carryforward Unused 0 0 0 0 0 0 0 0

10/30/2020 Page 42 of 52
 K L M N O P Q R S T
1 Group Name: enter group name here Exhibit 8
2 Group NAIC #: enter group # here Sheet 2
3 Year Filed: 2020
4
5
6 Calendar Year
7 2012 2011 2010 2009 2008 2007 2006 2005 2004 Total
8 0 0 0 0 0 0 0 0 0 0
9
10
11 Calendar Year Reinvestment
12 2012 2011 2010 2009 2008 2007 2006 2005 2004 Total
13 0 0 0 0 0 0 0 0 0 0
14 0 0 0 0 0 0 0 0 0 0
15 0 0 0 0 0 0 0 0 0 0
16 0 0 0 0 0 0 0 0 0 0
17 0 0 0 0 0 0 0 0 0 0
18 0 0 0 0 0 0 0 0 0 0
19 0 0 0 0 0 0 0 0 0 0
20 0 0 0 0 0 0 0 0 0 0
21 0 0 0 0 0 0 0 0 0 0
22 0 0 0 0 0 0 0 0 0 0
23 0 0 0 0 0 0 0 0 0 0
24 0 0 0 0 0 0 0 0 0 0
25 0 0 0 0 0 0 0 0 0 0
26 0 0 0 0 0 0 0 0 0 0
27 0 0 0 0 0 0 0 0 0 0
28 XXX 0 0 0 0 0 0 0 0 0
29 XXX XXX 0 0 0 0 0 0 0 0
30 XXX XXX XXX 0 0 0 0 0 0 0
31 XXX XXX XXX XXX 0 0 0 0 0 0
32 XXX XXX XXX XXX XXX 0 0 0 0 0
33 XXX XXX XXX XXX XXX XXX 0 0 0 0
34 XXX XXX XXX XXX XXX XXX XXX 0 0 0
35 XXX XXX XXX XXX XXX XXX XXX XXX 0 0
36
37 0 0 0 0 0 0 0 0 0 0
38
39 0 0 0 0 0 0 0 0 0 0

10/30/2020 Page 43 of 52
 A B C D E F G H I J
1 Group Name: enter group name here Exhibit 9
2 Group NAIC #: enter group # here
3 Year Filed: 2020
4
5 2013 2014 2015 2016 2017 2018 2019 7 Year Total
6 Item 1 Direct Calendar Year Written Premium Net of UCJF [Exhibit 1, Col (1), Item 3 - Item 4] 0 0 0 0 0 0 0 0
7 Item 2 Direct Calendar Year Earned Premium Net of UCJF [Exhibit 1, Col (1), Item 3 - Item 4] 0 0 0 0 0 0 0 0
8 Item 3 Dividends excluding Refund of Excess Profit [Exhibit 1, Col (3), Item 6] 0 0 0 0 0 0 0 0
9 Item 4 Net AIRE [Input Sheet, Exhibit 9, Item 5A + Item 5B - Item 5C] 0 0 0 0 0 0 0 0
10 Item 5 Direct CY Net Earned Premium [Item 2 - Item 3 + Item 4] 0 0 0 0 0 0 0 0
11
12 Item 6 Direct Accident Year Ultimate Loss & LAE [Exhibit 2, Part 4, Col (4)] 0 0 0 0 0 0 0 0
13
14 Item 7 Direct Commission & Brokerage Expense [Exhibit 3, Col (3), Item 5] 0 0 0 0 0 0 0 0
15 Item 8 Direct Other Acquisition Expense [Exhibit 3, Col (3), Item 3] 0 0 0 0 0 0 0 0
16 Item 9 Direct General Expense [Exhibit 3, Col (3), Item 4] 0 0 0 0 0 0 0 0
17 Item 10 Additional Allowable Expense [Exhibit 3, Col (3), Item 6] 0 0 0 0 0 0 0 0
18 Item 11 Direct Taxes, Licenses & Fees [Exhibit 3, Col (3), Item 7] 0 0 0 0 0 0 0 0
19 Item 12 Net Catastrophe Reinsurance [Exhibit 3, Col (3), Item 9] 0 0 0 0 0 0 0 0
20 Item 13 LAD Fees Paid [Exhibit 3, Col (3), Item 10] 0 0 0 0 0 0 0 0
21 Item 14 Total Expenses [Sum (Item 7 - Item 13)] 0 0 0 0 0 0 0 0
22
23 Item 15 Underwriting Income [Item 5 - Item 6 - Item 14] 0 0 0 0 0 0 0 0
24 Item 16 Target After-Tax Operating Return on Surplus #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!
25 Item 17 Actual Inv. Income Earned on Policyholder Supplied Funds [Exhibit 5, Item 15] 0 0 0 0 0 0 0 0
26 Item 18 Actuarial Gain [Item 15 - Item 16 + Item 17] #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!
27 Item 19 Total Development Adjustment [Input Sheet] 0 0 0 0 0 0 0 0
28 Item 20 Total Actuarial Gain [Item 18 - Item 19] #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!
29
30 Item 21 Additional Non-Excessive Profit Allowance 0 0 0 0 0 0 0 0
31 Item 22 Gross Excess Profit (Loss) [Item 20 - Item 21] #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!
32
33 Item 23 Carryforward of Refund of Excess Profit [Exhibit 6, Item 2] 0 0 0 0 0 0 0 0
34 Item 24 Carryforward of Extraordinary Loss [Exhibit 7, Item 2] 0 0 0 0 0 0 0 0
35 Item 25 Carryforward of Reinvestment into New Jersey [Exhibit 8, Item 2] 0 0 0 0 0 0 0 0
36 Item 26 Amount to be Reinvested into New Jersey ----- ----- ----- ----- ----- ----- ----- 0
37 Item 27 Net Excess Profit / (Loss) [Item 22 - Item 23 - Item 24 - Item 25 - Item 26] #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!
38
39 Item 28 Net Loss [-Item 27, if Item 27 is negative] #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!
40 Item 29a Additional Allowable Expense [Exhibit 3, Col (3), Item 6] 0 0 0 0 0 0 0 0
41 Item 29b Additional Non-Excessive Profit Allowance 0 0 0 0 0 0 0 0
42 Item 29 Sum of Above 2 Items 0 0 0 0 0 0 0 0
43 Item 30 Net Actual Loss [Item 28 - Item 29 if positive] #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!
44 Item 31 Extraordinary Loss [Item 30 - Item 2 * 5% if positive] #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!

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