PART B - CASE EXPERIENCE:

19___ 19___ 19___ 19___

1. Actual Earned Premiums

a. Net Written Premiums* _____ _____ _____ _____

b. Premium Reserve Beginning of Period _____ _____ _____ _____

c. Premium Reserve End of Period _____ _____ _____ _____

d. Earned Premiums (a+b-c) _____ _____ _____ _____

2. Earned Premiums at Presumptive Rates _____ _____ _____ _____

3. Incurred Claims

a. Claims Paid _____ _____ _____ _____

b. Unreported Claims, Beginning of Period _____ _____ _____ _____

c. Unreported Claims, End of Period _____ _____ _____ _____

d. Claim Reserve, Beginning of Period _____ _____ _____ _____

e. Claim Reserve, End of Period _____ _____ _____ _____

f. Incurred Claims, (a+b+c-d-e) _____ _____ _____ _____

4. Actual Loss Ratio for Case at Presumptive

Rates: 3(f) [divided by] 2 _____ _____ _____ _____

5. Average Number of Life Years _____ _____ _____ _____

6. Incurred Claim Count** _____ _____ _____ _____

*Net written premiums are to be determined as Gross Premium written (before deductions for dividends and experience rating credits) less refunds on terminations.

**Entries on 5. and 6. should be based on the Credibility Table elected by the insurer.

[13.18.2.32 NMAC - Rp, 13.18.2.32 NMAC, 3/11/2025]