DEPARTMENT OF LABOR AND REGULATION

1. (1) Additional

   1. (a) (2)

      Analysis

      Method

   2. (b) Other

      Amount

   3. (3) Total

      Amount

   4. (1) +(2)+(3)

   5. (4) Exhibit 5

      A Life Insurance

      -

      -

      -

      -

      -

      B Annuities

      -

      -

      -

      -

      -

      C Supplementary Contracts Involving

      Life Contingencies

      -

      -

      -

      -

      -

      D Accidental Death Benefit

      -

      -

      -

      -

      -

      E Disability - Active

      -

      -

      -

      -

      -

      F Disability - Disabled

      -

      -

      -

      -

      -

      G Miscellaneous

      -

      -

      -

      -

      -

      Total (Exhibit 5, Page 3, Line 1)

      -

      -

      -

      -

      -

      Exhibit 6

      A Active Life Reserve

      -

      -

      -

      -

      -

      B Claim Reserve

      -

      -

      -

      -

      -

      Total (Exhibit 6,

      Page 3, Line 1)

      -

      -

      -

      -

      -

      Exhibit 7

      Premium and other

      Deposit Funds

      -

      -

      -

      -

      -

      Guaranteed Interest

      Contracts

      -

      -

      -

      -

      -

      Other

      -

      -

      -

      -

      -

      Supplemental

      Contracts and

      Annuities Certain

      -

      -

      -

      -

      -

      Dividend

      Accumulations or

      Refunds

      -

      -

      -

      -

      -

      Total Exhibit 7

      (Page 3, Line 3)

      -

      -

      -

      -

      -

      Exhibit 8 Part 1

      1 Life (Page 3, Line

      4.1)

      -

      -

      -

      -

      -

      2 Health (Page 3,

      Line 4.2)

      -

      -

      -

      -

      -

      Total Exhibit 8, Part 1

      -

      -

      -

      -

      -

      Separate Accounts

      (Page 3 of the Annual

      Statement of the

      Separate Accounts,

      Lines 1, 2, 3.1, 3.2, 3.3)

      -

      -

      -

      -

      -

      TOTAL RESERVES

      -

      -

      -

      -

      -

      IMR (General Account, Page _____ Line _____)

      -

      (Separate Accounts, Page _____ Line _____)

      -

      AVR (Page _____ Line _____)

   6. (c) Net Deferred and Uncollected Premium

      -

   7. (a) The additional actuarial reserves are the reserves established under paragraphs 2 and 3 of § 20:06:37:08.
   8. (b) The appointed actuary should indicate the method of analysis, determined in accordance with the standards for asset adequacy analysis referred to in § 20:06:37:07, by means of symbols that should be defined in footnotes to the table.
   9. (c) Allocated amount of Asset Valuation Reserve (AVR).

   Actuarial

   Reserves

DIVISION OF INSURANCE

ASSET ADEQUACY TESTED AMOUNTS - RESERVES AND LIABILITIES

Chapter 20:06:37

APPENDIX A

SEE: § 20:06:37:32

APPENDIX A

ASSET ADEQUACY TESTED AMOUNTS - RESERVES AND LIABILITIES

Asset Adequacy Tested Amounts - Reserves and Liabilities

Statement Item

Formula

Reserves

Source: 23 SDR 236, effective July 16, 1997; 34 SDR 297, effective June 2, 2008.