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
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0
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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
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0
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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
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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
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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
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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
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0 0 0 0 0 0
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
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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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