Ill. Admin. Code tit. 50, § 928.EXHIBIT E – Supplement A to Schedule T Reconciliation Form

SCHEDULE T DATA RECONCILIATION FORM

Company Name:
Line Number	Line	Loss paid – number of claims	Losses paid – dollar amount
1	Schedule T, Supplement A
2	Part 928 claim report totals
3	Difference (line 1 - line 2)
Adjustments to Schedule T
4	Sch T – payments reported in current year on claims closed in prior years
5	Sch T – claims not reported in Part 928 claims data for other reasons (claim not reportable in this State, etc.; specify in separate explanation)
6	Correction for other discrepancies (occurrence vs. claims reporting, other accounting issues, etc.; specify in separate explanation)
7	Adjustments to Schedule T (line 1 - line 4 - line 5 - line 6)
Adjustments to 928 Claims Data
8	Claims not reported on Schedule T for other reasons (reported for another state, etc.; specify in separate explanation)
9	Other adjustments needed for claims data to reconcile to Schedule T
10	Adjustments to claims data (line 2 - line 8 - line 9)
Reconciled Amounts
11	Difference in adjusted amounts (line 7 - line 10) - this line should equal 0.
Explanation for adjustments on line 5:
Explanation for adjustments on line 6:
Explanation for adjustments on line 8:
Explanation for adjustments on line 9:

(Source: Amended at 40 Ill. Reg. 16137, effective November 30, 2016)