Report Affirmation Read me Instructions For 3425 f NYIL Compliance Report

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							                     NEW YORK STATE DEPARTMENT OF FINANCIAL SERVICES
                                    INSURANCE DIVISION
                PROPERTY BUREAU - MARKET ANALYSIS REGULATORY SERVICES UNIT

                                                    Instructions
                                       For 3425 (f) NYIL Compliance Report
1 The report format was prepared using Microsoft Excel.
2    The file name is 3425f.xls. ABSOLUTELY DO NOT:
 a   Insert any rows or columns in the report.
 b   Change any of the range names.
 c   Disable the protected feature.
 d   Change any of the formulae.
3 It is strongly recommended that you immediately save the "3425f.xls" file to your Hard Drive before inputting any
  data.

4 When entering data for this report, it is requested that every effort be made to conform to ISO territories. If you use
  non-ISO territories, please contact ISO for a conversion program. DO NOT ATTEMPT to change territories or
  territory numbers without first contacting ISO.

5 Classes - A given policy should appear in the report only once and should be included in whichever class is
  considered primary by the insurer. (e.g., A family auto driven by both an adult and a youthful male might be primarily
  classified as youthful male. For the purposes of this report, it should appear only once, either as "Adult Class" or as
  "Youthful Male Class", but not in both.) Note that all classes should conform to filed ISO classes.


6 Affirmation Worksheet
  In this worksheet, complete the INSURER and CONTACT information; and answer the 2 questions concerning multi-
  tier program.
  A hard copy of the "Affirmation" must be completed and signed by an officer of the company.
  ("Up-tier" worksheet must be completed if you answered "yes" to both questions.)
7 Report Worksheet
  Note that Assigned Risk, Motor Home and Motorcycle polices should not be included.

     Data required for each columns are self-explanatory. For cells that may not be self-explanatory, additional
     information can be viewed by placing cursor over the appropriate cell to view the message.
     In this worksheet, enter the reporting year and complete the INSURER and CONTACT information in cells B1
     through B9.

     Tables for "ADULT CLASS", "SENIOR CITIZEN CLASS", "YOUTHFUL MALE CLASS" and "YOUTHFUL FEMALE
     In Column:
          1       Enter here the number of policies-in-force as of December 31st, of the preceding calendar year.
                  This column is needed because the "2%" calculation is based on the number of policies in force at last
                  year-end.
          2       Enter here the number of policies-in-force as of January 1st, of the reporting calendar year.
                  Note that the number of policies in force in column (1) should equal or similar to the number of
                  policies in force in column (2). If it does not, please submit an explanation.
          3       Enter here the new policies written during the reporting period.
          4       Enter here the number of policies that were cancelled by Insurer during the first sixty days of a covered
                  policy in accordance with Section 3425 (b) of the Insurance Law.
          5       Enter here the number of policies that were cancelled by Insurer after the first sixty days of a covered
                  policy in accordance with Section 3425 (c) of the Insurance Law.
          6       Enter here the number of policies that were cancelled or not renewed by policyholders.
          7       Enter here the number of policies that were not renewed by Insurer.
          8       Enter here the number of policies that were conditionally renewed by Insurer in accordance with Section
                  3425 (d)(1) & Section 3425 (f)(1) of the Insurance Law.
        9       Enter here any books of business transferred in from another company with prior New York State
                Insurance Department acknowledgement.
        10      Enter here any books of business transferred out to another company with prior New York State
                Insurance Department acknowledgement.
                Please submit a copy of the Insurance Department's acknowledgement letter if data were
                reported in columns 9 & 10.
        11      Enter here any books of business transferred in from another company without prior New York State
                Insurance Department acknowledgement.
        12      Enter here any books of business transferred out to another company without prior New York State
                Insurance Department acknowledgement.
                Note that policies "transferred out" of company without prior NYSID acknowledgement could be
                treated the same as policies non-renewed by insurer; and the “transferred out” polices may also
                be subject to the “2%” limitation.
        13      Policies-in-force as of December 31st, of the reporting calendar year. This column is pre-formulated
                and protected. DO NOT enter data here.

   "COMBINED ALL CLASSES" table is pre-formulated and protected. DO NOT enter data in this table.

8 The "Up-tier" worksheet should be completed by Insurer with an approved multi-tiering program.
   Use this worksheet to report the number of policies moved from lower rated tiers to higher rated tiers.
   Data required for each columns are self-explanatory. For cells that may not be self-explanatory, additional
   information can be viewed by placing cursor over the appropriate cell to view the message.
   In Column:
        1     Enter here the number of policies-in-force as of December 31st, of the preceding calendar year.
        2     Enter here the new policies written during the reporting period.
        3     Enter here the number of policies that were cancelled by Insurer during the first sixty days of a covered
              policy in accordance with Section 3425 (b) of the Insurance Law.
        4     Enter here the number of policies moved from lower rated tiers to higher rated tiers.
   Note that the number of policies moved from lower rated tiers to higher rated tiers in each of the rating
   territories for each calendar year shall be limited to three percent of the total number of private passenger
   automobile policies in force in that territory at last year-end pursuant to Section 2349 of the Insurance Law.



9 Due Date : Annually, April 30th.

10 What to submit to The Department:
   The completed Excel file should be submitted to the Department via e-mail as
   an attachment addressed to peter.wong@dfs.ny.gov

   The signed "Affirmation" should be mailed to following address:
   New York State Department of Financial Services
   25 Beaver Street
   Property Bureau - 2nd Floor
   New York, NY 10004-2319
   Attn: MARS Unit - Annual 3425f Compliance Report

   As an alternative, you may save the completed file(s) on a blank CD-R and mail it in a CD mailer along with
   the signed "Affirmation" to the address above.
   Note that the Department does not require a printed copy of the report. The only
   hard copy that is required is the signed "Affirmation".

   If you experience any difficulties in using this file, contact Mr. Peter Wong by phone at (212) 480-5591,
   or by e-mail at peter.wong@dfs.ny.gov
Data reporting period:
Group #:
NAIC #:
Company Name:
Mail Address:
City:
State:
ZIP Code:

Contact Info:
Mr.Mrs.Ms. Etc.:
First Name & MI:
Last Name:
Jr.Sr.II CPCU Etc.
Title:
Direct Telephone:
FAX Number:
E-Mail Address




Multi-tier Program General Questionnaire:
1. Does your company have an approved multi-tier private passenger auto plan?                        Yes             No
   If yes, answer number 2.

2. Does your company's approved multi-tier private passenger auto plan include                       Yes             No
   rules for up-tiering?
   If yes, fill in the data for your company on the "Up-tier" worksheet.



                                       Section 3425(f) NYIL Compliance Report
                                                   For Year Ended
                                                          0

AFFIRMATION

         I,                                                   ,the duly authorized Senior Under-writing Officer of
                             0                                do hereby affirm, under penalty of perjury, that the
information contained in this letter and the attached report, including any attached exhibits,
schedules, and other supporting information, is true to the best of my knowledge and belief.



     Date:
                                                                  Signature of Senior Underwriting Officer

     Title:
                                                                Printed Name of Senior Underwriting Officer
     Enter Reporting Year here
     Enter 4 digit NAIC Group Here                             COMPLIANCE REPORT
     Enter 5 digit NAIC Number Here                       (Section 3425(f) New York Insurance Law)
     Enter Company Name
     Enter 1st Line of Address                         RECONCILIATION OF POLICIES IN FORCE
     Enter City, State, Zip Code                        BEGINNING OF YEAR TO END OF YEAR
     Enter Contact Person Name                                    ADULT CLASS
     Enter Contact's Telephone Number
     Enter Contact's E-mail Address
                                             (1)         (2)          (3)
                                                                     ADD
                                           POLICIES    POLICIES      NEW
                                              IN          IN       POLICIES
                                            FORCE       FORCE      WRITTEN
                                             12/31        1/1       DURING
                                            OF THE      OF THE       YEAR
                                          PRECEDING   REPORTING
     TERRITORIES                        CALENDAR YEAR    YEAR
01   BRONX
03   BRONX SUB.
05   STATEN ISLAND
07   BUFFALO
08   BUFFALO SEMI-SUB.
09   SCHENECTADY CO.
11   ROCHESTER
12   SYRACUSE
13   ALBANY
14   NIAGARA FALLS
15   UTICA
16   SARATOGA SPRINGS SUB.
17   KINGS CO.
18   MANHATTAN
19   QUEENS
20   HEMPSTEAD
21   NORTH HEMPSTEAD
22   OYSTER BAY
24   ROME
25   AUBURN
27   ELMIRA
28   BINGHAMTON
29   GLOVERSVILLE
30   SARATOGA SPRINGS
31   CHAUTAUQUA CO.
32   NEWBURGH
33   POUGHKEEPSIE
34   TROY
35   AMSTERDAM
36   GLENS FALLS
37   OSWEGO
38   SYRACUSE SUB.
39   ROCHESTER SUB.
40   CORNING
41   ERIE COUNTY (BAL)
42   BUFFALO SUB.
43   NIAGARA FALLS SUB.
44   BROOME CO. (BAL)
46   PUTNAM CO.
47   ORLEANS CO.
48   MONROE CO. (BAL)
49   NIAGARA CO. (BAL)
51   ONTARIO CO., ETC.
52   FORT PLAIN, HERKIMER
54   CORTLAND CO., ETC.
55   QUEENS SUB.
56   SARATOGA CO. (BAL)
58   DUTCHESS CO. (BAL)
59   COLUMBIA CO., ETC.
60   GENESEE CO.
61   DELAWARE CO., ETC.
62   HIGHLAND, KINGSTON
64   MIDDLETOWN
65   OSSINING
67   CLINTON CO., ETC.
68   ROCKLAND CO.
71   SARATOGA CO. SOUTH
72   ALBANY CO. (BAL)
73   RENSSELAER CO. (BAL)
74   JEFFERSON CO.
75   SUFFOLK CO. WEST
76   SUFFOLK CO. EAST
81   MONTICELLO-LIBERTY
82   SULLIVAN CO. CENTRAL
83   SULLIVAN CO. (BAL)
84   ALLEGHENY CO., ETC.
86   ONEIDA
94   MT. VERNON & YONKERS
95   WHITE PLAINS
97   NEW YORK CITY SUB.
STATE TOTALS   0   0   0
MPLIANCE REPORT                                                                COMPLIANCE REP
425(f) New York Insurance Law)                                             (Section 3425(f) New York Insu

ATION OF POLICIES IN FORCE                                             RECONCILIATION OF POLICI
G OF YEAR TO END OF YEAR                                                BEGINNING OF YEAR TO EN
  ADULT CLASS                                                                     ADULT CLASS


                 (4)       (5)     (6)         (7)          (8)                      TRANSFERS OF BO
              (LESS)    (LESS)   (LESS)      (LESS)                          WITH PRIOR NYSID
            POLICIES  POLICIES  POLICIES    POLICIES     POLICIES          ACKNOWLEDGEMENT
           CANCELLED CANCELLED CANCELLED      NOT      CONDITIONALLY        (9)
                 BY        BY      OR       RENEWED      RENEWED          (ADD)
            COMPANY   COMPANY NOT RENEWED      BY           BY           POLICIES
             DURING     AFTER      BY       COMPANY      COMPANY       TRANSFERRED
               FIRST     FIRST  INSURED                                     IN
             60 DAYS   60 DAYS
0   0   0   0   0   0
     COMPLIANCE REPORT                                                                COMPLIAN
 (Section 3425(f) New York Insurance Law)                                        (Section 3425(f) New

CONCILIATION OF POLICIES IN FORCE                                            RECONCILIATION OF
EGINNING OF YEAR TO END OF YEAR                                               BEGINNING OF YEA
         ADULT CLASS                                                                SENIOR CIT


         TRANSFERS OF BOOKS OF BUSINESS                 (13)        (1)         (2)
 WITH PRIOR NYSID            WITHOUT PRIOR NYSID
ACKNOWLEDGEMENT               ACKNOWLEDGEMENT         POLICIES    POLICIES    POLICIES
                (10)          (11)           (12)        IN          IN          IN
              (LESS)         (ADD)         (LESS)      FORCE       FORCE       FORCE
             POLICIES      POLICIES       POLICIES      12/31       12/31        1/1
           TRANSFERRED TRANSFERRED TRANSFERRED         OF THE      OF THE      OF THE
               OUT             IN           OUT      REPORTING   PRECEDING   REPORTING
                                                        YEAR   CALENDAR YEAR    YEAR
                                                               0
                                                               0
                                                               0
                                                               0
                                                               0
                                                               0
                                                               0
                                                               0
                                                               0
                                                               0
                                                               0
                                                               0
                                                               0
                                                               0
                                                               0
                                                               0
                                                               0
                                                               0
                                                               0
                                                               0
                                                               0
                                                               0
                                                               0
                                                               0
                                                               0
                                                               0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0   0   0   0   0   0
       COMPLIANCE REPORT                                                                   COMPLI
   (Section 3425(f) New York Insurance Law)                                            (Section 3425(f)

RECONCILIATION OF POLICIES IN FORCE                                                 RECONCILIATION
 BEGINNING OF YEAR TO END OF YEAR                                                    BEGINNING OF
       SENIOR CITIZEN CLASS                                                                SENIOR


               (3)            (4)       (5)     (6)         (7)          (8)
              ADD          (LESS)    (LESS)   (LESS)      (LESS)                        WITH PRIOR N
              NEW        POLICIES  POLICIES  POLICIES    POLICIES     POLICIES
            POLICIES    CANCELLED CANCELLED CANCELLED      NOT      CONDITIONALLY
            WRITTEN           BY        BY      OR       RENEWED      RENEWED
             DURING      COMPANY   COMPANY NOT RENEWED      BY           BY
              YEAR        DURING     AFTER      BY       COMPANY      COMPANY
                            FIRST     FIRST  INSURED
                          60 DAYS   60 DAYS
0   0   0   0   0   0
        COMPLIANCE REPORT
    (Section 3425(f) New York Insurance Law)                              (S

RECONCILIATION OF POLICIES IN FORCE                                     RECO
 BEGINNING OF YEAR TO END OF YEAR                                        BEG
       SENIOR CITIZEN CLASS


              TRANSFERS OF BOOKS OF BUSINESS                 (13)
      WITH PRIOR NYSID            WITHOUT PRIOR NYSID
    ACKNOWLEDGEMENT                ACKNOWLEDGEMENT         POLICIES
     (9)             (10)          (11)           (12)        IN
   (ADD)           (LESS)         (ADD)         (LESS)      FORCE
  POLICIES        POLICIES      POLICIES       POLICIES      12/31
TRANSFERRED TRANSFERRED TRANSFERRED TRANSFERRED             OF THE
     IN             OUT             IN           OUT      REPORTING
                                                             YEAR
                                                                    0
                                                                    0
                                                                    0
                                                                    0
                                                                    0
                                                                    0
                                                                    0
                                                                    0
                                                                    0
                                                                    0
                                                                    0
                                                                    0
                                                                    0
                                                                    0
                                                                    0
                                                                    0
                                                                    0
                                                                    0
                                                                    0
                                                                    0
                                                                    0
                                                                    0
                                                                    0
                                                                    0
                                                                    0
                                                                    0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0   0   0   0   0
                       COMPLIANCE REPORT
                  (Section 3425(f) New York Insurance Law)

              RECONCILIATION OF POLICIES IN FORCE
               BEGINNING OF YEAR TO END OF YEAR
                    YOUTHFUL MALE CLASS


     (1)         (2)          (3)             (4)       (5)     (6)
                             ADD           (LESS)    (LESS)   (LESS)
   POLICIES    POLICIES      NEW         POLICIES  POLICIES  POLICIES
      IN          IN       POLICIES     CANCELLED CANCELLED CANCELLED
    FORCE       FORCE      WRITTEN            BY        BY      OR
     12/31        1/1       DURING       COMPANY   COMPANY NOT RENEWED
    OF THE      OF THE       YEAR         DURING     AFTER      BY
  PRECEDING   REPORTING                     FIRST     FIRST  INSURED
CALENDAR YEAR    YEAR                     60 DAYS   60 DAYS
0   0   0   0   0   0
                                   COMPLIANCE REPORT
                               (Section 3425(f) New York Insurance Law)

                           RECONCILIATION OF POLICIES IN FORCE
                            BEGINNING OF YEAR TO END OF YEAR
                                 YOUTHFUL MALE CLASS


   (7)          (8)                      TRANSFERS OF BOOKS OF BUSINESS
 (LESS)                          WITH PRIOR NYSID            WITHOUT PRIOR NYSID
POLICIES     POLICIES          ACKNOWLEDGEMENT                ACKNOWLEDGEMENT
  NOT      CONDITIONALLY        (9)             (10)          (11)
RENEWED      RENEWED          (ADD)           (LESS)         (ADD)
   BY           BY           POLICIES        POLICIES      POLICIES
COMPANY      COMPANY       TRANSFERRED TRANSFERRED TRANSFERRED
                                IN             OUT             IN
0   0   0   0   0
                                                          COMPLIANCE REPORT
Law)                                                 (Section 3425(f) New York Insurance Law)

FORCE                                             RECONCILIATION OF POLICIES IN FORCE
YEAR                                               BEGINNING OF YEAR TO END OF YEAR
                                                        YOUTHFUL FEMALE CLASS


F BUSINESS                  (13)        (1)         (2)          (3)            (4)
WITHOUT PRIOR NYSID                                             ADD          (LESS)
ACKNOWLEDGEMENT           POLICIES    POLICIES    POLICIES      NEW        POLICIES
                (12)         IN          IN          IN       POLICIES    CANCELLED
              (LESS)       FORCE       FORCE       FORCE      WRITTEN           BY
             POLICIES       12/31       12/31        1/1       DURING      COMPANY
           TRANSFERRED     OF THE      OF THE      OF THE       YEAR        DURING
               OUT       REPORTING   PRECEDING   REPORTING                    FIRST
                            YEAR   CALENDAR YEAR    YEAR                    60 DAYS
                                   0
                                   0
                                   0
                                   0
                                   0
                                   0
                                   0
                                   0
                                   0
                                   0
                                   0
                                   0
                                   0
                                   0
                                   0
                                   0
                                   0
                                   0
                                   0
                                   0
                                   0
                                   0
                                   0
                                   0
                                   0
                                   0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0   0   0   0   0   0
 REPORT                                                              COMPLIANCE REPORT
k Insurance Law)                                                 (Section 3425(f) New York Insurance Law)

OLICIES IN FORCE                                             RECONCILIATION OF POLICIES IN FORC
TO END OF YEAR                                                BEGINNING OF YEAR TO END OF YEAR
ALE CLASS                                                          YOUTHFUL FEMALE CLASS


                 (5)     (6)         (7)          (8)                      TRANSFERS OF BOOKS OF BUSIN
              (LESS)   (LESS)      (LESS)                          WITH PRIOR NYSID            WITHOU
            POLICIES  POLICIES    POLICIES     POLICIES          ACKNOWLEDGEMENT
           CANCELLED CANCELLED      NOT      CONDITIONALLY        (9)             (10)
                 BY      OR       RENEWED      RENEWED          (ADD)           (LESS)
            COMPANY NOT RENEWED      BY           BY           POLICIES        POLICIES
              AFTER      BY       COMPANY      COMPANY       TRANSFERRED TRANSFERRED
               FIRST  INSURED                                     IN             OUT
             60 DAYS
0   0   0   0   0   0
NCE REPORT                                                              COMPLIANCE REPORT
ew York Insurance Law)                                             (Section 3425(f) New York Insurance La

OF POLICIES IN FORCE                                            RECONCILIATION OF POLICIES IN F
EAR TO END OF YEAR                                               BEGINNING OF YEAR TO END OF Y
FEMALE CLASS                                                            ALL OTHER CLASSES


FERS OF BOOKS OF BUSINESS                 (13)        (1)         (2)          (3)
               WITHOUT PRIOR NYSID                                            ADD
                ACKNOWLEDGEMENT         POLICIES    POLICIES    POLICIES      NEW
                (11)           (12)        IN          IN          IN       POLICIES
               (ADD)         (LESS)      FORCE       FORCE       FORCE      WRITTEN
             POLICIES       POLICIES      12/31       12/31        1/1       DURING
           TRANSFERRED TRANSFERRED       OF THE      OF THE      OF THE       YEAR
                 IN           OUT      REPORTING   PRECEDING   REPORTING
                                          YEAR   CALENDAR YEAR    YEAR
                                                 0
                                                 0
                                                 0
                                                 0
                                                 0
                                                 0
                                                 0
                                                 0
                                                 0
                                                 0
                                                 0
                                                 0
                                                 0
                                                 0
                                                 0
                                                 0
                                                 0
                                                 0
                                                 0
                                                 0
                                                 0
                                                 0
                                                 0
                                                 0
                                                 0
                                                 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0   0   0   0   0   0
MPLIANCE REPORT                                                                COMPLIANCE REP
425(f) New York Insurance Law)                                             (Section 3425(f) New York Insu

ATION OF POLICIES IN FORCE                                             RECONCILIATION OF POLICI
G OF YEAR TO END OF YEAR                                                BEGINNING OF YEAR TO EN
LL OTHER CLASSES                                                               ALL OTHER CLASS


                 (4)       (5)     (6)         (7)          (8)                      TRANSFERS OF BO
              (LESS)    (LESS)   (LESS)      (LESS)                          WITH PRIOR NYSID
            POLICIES  POLICIES  POLICIES    POLICIES     POLICIES          ACKNOWLEDGEMENT
           CANCELLED CANCELLED CANCELLED      NOT      CONDITIONALLY        (9)
                 BY        BY      OR       RENEWED      RENEWED          (ADD)
            COMPANY   COMPANY NOT RENEWED      BY           BY           POLICIES
             DURING     AFTER      BY       COMPANY      COMPANY       TRANSFERRED
               FIRST     FIRST  INSURED                                     IN
             60 DAYS   60 DAYS
0   0   0   0   0   0
     COMPLIANCE REPORT                                                                   COMPLIANC
 (Section 3425(f) New York Insurance Law)                                           (Section 3425(f) New

CONCILIATION OF POLICIES IN FORCE                                               RECONCILIATION OF
EGINNING OF YEAR TO END OF YEAR                                                  BEGINNING OF YEA
      ALL OTHER CLASSES                                                               COMBINED A


         TRANSFERS OF BOOKS OF BUSINESS                 (13)          (1)          (2)
 WITH PRIOR NYSID            WITHOUT PRIOR NYSID
ACKNOWLEDGEMENT               ACKNOWLEDGEMENT         POLICIES      POLICIES    POLICIES
                (10)          (11)           (12)        IN            IN          IN
              (LESS)         (ADD)         (LESS)      FORCE         FORCE       FORCE
             POLICIES      POLICIES       POLICIES      12/31         12/31        1/1
           TRANSFERRED TRANSFERRED TRANSFERRED         OF THE        OF THE      OF THE
               OUT             IN           OUT      REPORTING     PRECEDING   REPORTING
                                                        YEAR     CALENDAR YEAR    YEAR
                                                               0             0           0
                                                               0             0           0
                                                               0             0           0
                                                               0             0           0
                                                               0             0           0
                                                               0             0           0
                                                               0             0           0
                                                               0             0           0
                                                               0             0           0
                                                               0             0           0
                                                               0             0           0
                                                               0             0           0
                                                               0             0           0
                                                               0             0           0
                                                               0             0           0
                                                               0             0           0
                                                               0             0           0
                                                               0             0           0
                                                               0             0           0
                                                               0             0           0
                                                               0             0           0
                                                               0             0           0
                                                               0             0           0
                                                               0             0           0
                                                               0             0           0
                                                               0             0           0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0
0   0   0   0   0   0
       COMPLIANCE REPORT                                                                             COMPL
   (Section 3425(f) New York Insurance Law)                                                      (Section 3425(f

RECONCILIATION OF POLICIES IN FORCE                                                           RECONCILIATIO
 BEGINNING OF YEAR TO END OF YEAR                                                              BEGINNING OF
      COMBINED ALL CLASSES                                                                          COMBIN


               (3)               (4)        (5)      (6)          (7)              (8)
              ADD             (LESS)     (LESS)    (LESS)       (LESS)                          WITH PRIOR NY
              NEW           POLICIES   POLICIES   POLICIES     POLICIES         POLICIES
            POLICIES       CANCELLED CANCELLED CANCELLED         NOT          CONDITIONALLY
            WRITTEN              BY         BY       OR        RENEWED          RENEWED
             DURING         COMPANY    COMPANY NOT RENEWED        BY               BY
              YEAR           DURING      AFTER       BY        COMPANY          COMPANY
                               FIRST      FIRST   INSURED
                             60 DAYS    60 DAYS
                       0             0          0          0              0               0
                       0             0          0          0              0               0
                       0             0          0          0              0               0
                       0             0          0          0              0               0
                       0             0          0          0              0               0
                       0             0          0          0              0               0
                       0             0          0          0              0               0
                       0             0          0          0              0               0
                       0             0          0          0              0               0
                       0             0          0          0              0               0
                       0             0          0          0              0               0
                       0             0          0          0              0               0
                       0             0          0          0              0               0
                       0             0          0          0              0               0
                       0             0          0          0              0               0
                       0             0          0          0              0               0
                       0             0          0          0              0               0
                       0             0          0          0              0               0
                       0             0          0          0              0               0
                       0             0          0          0              0               0
                       0             0          0          0              0               0
                       0             0          0          0              0               0
                       0             0          0          0              0               0
                       0             0          0          0              0               0
                       0             0          0          0              0               0
                       0             0          0          0              0               0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
0   0   0   0   0   0
          COMPLIANCE REPORT
      (Section 3425(f) New York Insurance Law)

  RECONCILIATION OF POLICIES IN FORCE
   BEGINNING OF YEAR TO END OF YEAR
        COMBINED ALL CLASSES


              TRANSFERS OF BOOKS OF BUSINESS                 (13)
      WITH PRIOR NYSID            WITHOUT PRIOR NYSID
    ACKNOWLEDGEMENT                ACKNOWLEDGEMENT         POLICIES
     (9)             (10)          (11)           (12)        IN
   (ADD)           (LESS)         (ADD)         (LESS)      FORCE
  POLICIES        POLICIES      POLICIES       POLICIES      12/31
TRANSFERRED TRANSFERRED TRANSFERRED TRANSFERRED             OF THE
     IN             OUT             IN           OUT      REPORTING
                                                             YEAR
             0                 0                 0    0               0
             0                 0                 0    0               0
             0                 0                 0    0               0
             0                 0                 0    0               0
             0                 0                 0    0               0
             0                 0                 0    0               0
             0                 0                 0    0               0
             0                 0                 0    0               0
             0                 0                 0    0               0
             0                 0                 0    0               0
             0                 0                 0    0               0
             0                 0                 0    0               0
             0                 0                 0    0               0
             0                 0                 0    0               0
             0                 0                 0    0               0
             0                 0                 0    0               0
             0                 0                 0    0               0
             0                 0                 0    0               0
             0                 0                 0    0               0
             0                 0                 0    0               0
             0                 0                 0    0               0
             0                 0                 0    0               0
             0                 0                 0    0               0
             0                 0                 0    0               0
             0                 0                 0    0               0
             0                 0                 0    0               0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
0   0   0   0   0
     Enter Reporting Year here
     Enter 4 digit NAIC Group Here
     Enter 5 digit NAIC Number Here                   COMPLIANCE REPORT
     Enter Company Name
                                                   (Section 2349 New York Insurance Law)
     Enter 1st Line of Address
     Enter City, State, Zip Code
     Enter Contact Person Name
     Enter Contact's Telephone Number
     Enter Contact's E-mail Address
                                             (1)             (2)           (3)

                                           POLICIES         NEW        POLICIES
                                              IN          POLICIES    CANCELLED
                                            FORCE         WRITTEN          BY
                                             12/31         DURING      COMPANY
                                            OF THE          YEAR        DURING
                                          PRECEDING                      FIRST
     TERRITORIES                        CALENDAR YEAR                   60 DAYS
01   BRONX
03   BRONX SUB.
05   STATEN ISLAND
07   BUFFALO
08   BUFFALO SEMI-SUB.
09   SCHENECTADY CO.
11   ROCHESTER
12   SYRACUSE
13   ALBANY
14   NIAGARA FALLS
15   UTICA
16   SARATOGA SPRINGS SUB.
17   KINGS CO.
18   MANHATTAN
19   QUEENS
20   HEMPSTEAD
21   NORTH HEMPSTEAD
22   OYSTER BAY
24   ROME
25   AUBURN
27   ELMIRA
28   BINGHAMTON
29   GLOVERSVILLE
30   SARATOGA SPRINGS
31   CHAUTAUQUA CO.
32   NEWBURGH
33   POUGHKEEPSIE
34   TROY
35   AMSTERDAM
36   GLENS FALLS
37   OSWEGO
38   SYRACUSE SUB.
39   ROCHESTER SUB.
40   CORNING
41   ERIE COUNTY (BAL)
42   BUFFALO SUB.
43   NIAGARA FALLS SUB.
44   BROOME CO. (BAL)
46   PUTNAM CO.
47   ORLEANS CO.
48   MONROE CO. (BAL)
49   NIAGARA CO. (BAL)
51   ONTARIO CO., ETC.
52   FORT PLAIN, HERKIMER
54   CORTLAND CO., ETC.
55   QUEENS SUB.
56   SARATOGA CO. (BAL)
58   DUTCHESS CO. (BAL)
59   COLUMBIA CO., ETC.
60   GENESEE CO.
61   DELAWARE CO., ETC.
62   HIGHLAND, KINGSTON
64   MIDDLETOWN
65   OSSINING
67   CLINTON CO., ETC.
68   ROCKLAND CO.
71   SARATOGA CO. SOUTH
72   ALBANY CO. (BAL)
73   RENSSELAER CO. (BAL)
74   JEFFERSON CO.
75   SUFFOLK CO. WEST
76   SUFFOLK CO. EAST
81   MONTICELLO-LIBERTY
82   SULLIVAN CO. CENTRAL
83   SULLIVAN CO. (BAL)
84   ALLEGHENY CO., ETC.
86   ONEIDA
94   MT. VERNON & YONKERS
95   WHITE PLAINS
97   NEW YORK CITY SUB.
               STATE TOTALS   0   0
 REPORT
k Insurance Law)




                   (4)

               POLICIES
             MOVED FROM
             A LOWER TIER
                  TO
             A HIGHER TIER
0

						
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