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Reconciliation of Premium Accounts per SBO vs. AFS


as of December 31, ____

Note/s and Instruction/s:


Add rows on the Reconciling items section, if necessary.

Policyholder Ceding Company HMO Total Justification

Premiums Receivable, end (per SBO) - - - -


Add/Less Reconciling items:
[description] - - - -
[description] - - - -
[description] - - - -
Balance, Audited AFS - - - -

Insurance Company Reinsurer HMO Total

Premiums Payable, end (per SBO) - - - -


Add/Less Reconciling items:
[description] - - - -
[description] - - - -
[description] - - - -
Balance, Audited AFS - - - -

Commissions Receivable, end (per SBO) -


Add/Less Reconciling items:
[description] -
[description] -
[description] -
Balance, Audited AFS -

Commissions Revenue, (per SBO) -


Reconciling items:
[description] -
[description] -
[description] -
Balance, Audited AFS -

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