Notary Public Certificate of Acknowledgement

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Notary Public Certificate of Acknowledgement Powered By Docstoc
					State of California                                                                                        DEPARTMENT OF INSURANCE
VALUATIONS OF SECURITIES
FAD A110 (2/11)
Form                                                                                 Due                        Download
 No.                           Description                                           Date                        Format
A110                     Valuations of Securities
               (For Workers' Compensation Securities Only)                                                        EXCEL

                           As of December 31, 2010                              March 1, 2011

                            As of March 31, 2011                                May 15, 2011

                              and Upon Request                                  As Requested

         FOR INSURERS LICENSED TO TRANSACT WORKERS'                                        SUBMIT VIA OASIS
            COMPENSATION INSURANCE IN CALIFORNIA OR                                    1 FILE IN EXCEL FORMAT
        AUTHORIZED TO REINSURE THE INJURY, DISABLEMENT,                             1 SIGNED FILE IN PDF FORMAT
           OR DEATH PORTIONS OF POLICIES OF WORKERS'                                    SUBMIT IN HARDCOPY
          COMPENSATION INSURANCE UNDER THE CLASS OF                               1 ORIGINAL CERTIFICATION PAGE
                     DISABILITY INSURANCE.                                 1 ORIGINAL NOTARIZATION PAGE, IF APPLICABLE

                                    INSTRUCTIONS FOR INITIAL FILING AND AMENDED FILING
  1    DOWNLOADING the FILE:
       - Download the Excel file onto your computer.
       - Prior versions of this form will not be accepted for current year's filing.
  2    SAVE FILE AS:                       PLEASE FOLLOW THESE INSTRUCTIONS

        - Rename your file according to the following example:
          A110 as of December 31, 2010 due March 1, 2011……….…...         COMPANY NAME-A110DEC2010.xls
          A110 as of December 31, 2010 due March 1, 2011……….……           COMPANY NAME-A110DEC2010.pdf
          A110 as of March 31, 2011 due May 15, 2011……….…………             COMPANY NAME-A110MAR2011.xls
          A110 as of March 31, 2010 due May 15, 2011……….…………             COMPANY NAME-A110MAR2011.pdf

        - When submitting an amended filling, rename your file according to the following example:
           A110 as of March 31, 2011 Amended June 1, 2011……….…………            COMPANY NAME-A110MAR2011-Amended-6-1-11.xls
           A110 as of March 31, 2011 Amended June 1, 2011……….…………            COMPANY NAME-A110MAR2011-Amended-6-1-11.pdf
  3    FILE CONTENTS:
       Worksheet Subject                                                                               Worksheet Title
        - Instructions (This worksheet)                                                                Instructions
        - Listing of securities on deposit for CA workers' compensation business in detail             Pages 1 to 10
        - Certification Page - PRINT AND FILL OUT MANUALLY                                             Certification
        - CA Notary Page - MUST be used by CA Notaries: (PRINT AND FILL OUT MANUALLY)                  CA Notary
        - Answers to commonly asked questions                                                          Q&A
        - List of company names (refer to instruction # 4 below)                                       Page A
        - (Hidden, For CDI Internal Use Only, Do Not Print)                                            (CDI Data coinfo)
        - (Hidden, For CDI Internal Use Only, Do Not Print)                                            (CDI Data sec)
  4    DATA ENTRY:
        - Enter the data in the tan colored cells only.
        - Do not skip rows and do not format cells.
        - If you are pasting information, use the paste value function only. DO NOT PASTE OR USE FORMULAS.
        - Do not insert additional rows, use pages 1-10 for listing your securities.
        - On page 1, if your company name does not appear after you enter your NAIC Number, go to "Page A, Part 1"
          and enter the required information to proceed.
        - It is the company's responsibility to make sure the NAIC numbers are correct and current.
  5    LOC INSTRUCTIONS:
        - Identify issuing institution under Column (2) and indicate the LOC amount on Column (6).
        - Mail a copy of the LOC(s) on deposit for California Workers' Compensation to address on item 7 below.
  6    PRINTING:
        - Print out pages used (in legal size).
        - Authorized Officer must sign page 1.
        - The "Certification" page and "CA Notary" page (if applicable) MUST be completed and submitted in hardcopy.
  7    FILING:
        - Mail 1 original hardcopy of the Certification Page with the Company's Name and NAIC No.
        - Mail 1 original hardcopy of the Notarization Page (if applicable) with the Company's Name and NAIC No.

                                                       to:

                                        California Department of Insurance
                                        Financial Analysis Division
                                        300 South Spring Street, South Tower, 13th floor
                                        Los Angeles, CA 90013
                                        Attn: Financial Records Unit

        - For questions regarding filing, please contact the Financial Records Unit at (213) 346-6423.
        - For questions concerning the calculations and/or completing this form, please contact WCDRT at (213) 346-6433.
  8     - Your filing must be received by the Department's Financial Records Unit postmarked no later than the due date
          stated above. Late and incomplete filings will be assessed a late filing fee prescribed in the CA Insurance Code.
        - It is a criminal offense if you intentionally submit forms electronically (by email) containing viruses or other
          materials that would cause harm to the Department.
State of California                                                                       Securities which are held on deposit with the State of California under California Insurance Code Section 11691.                                                DEPARTMENT OF INSURANCE
VALUATIONS OF SECURITIES
FAD A110 (2/11)                                                                           FOR INITIAL FILING, COMPLETE PART A AND C ONLY. FOR AMENDED FILING, COMPLETE PART B AND C ONLY, LEAVE PART A BLANK.

                                                   Part A for INITIAL FILING - As of Date (Click on cell and select the appropriate date):
                                                 Part B for AMENDED FILING- As of Date (Click on cell and select the appropriate date):                              Date Amended:
Part C
NAIC NO.
COMPANY                                                                                                                                      For Col. 1 - Group security items in the following NAIC order and alphabetically within each group:
NAIC GROUP NO.                                                                                                                               1. Governments (including all obligations guaranteed by government)
STREET ADDRESS                                                                                                                               2. States, Territories, and Possessions (Direct & Guaranteed)
CITY, STATE, & ZIP                                                                                                                           3. Political Subdivisions of States, Territories, and Possessions (Direct & Guaranteed)
CONTACT NAME                                                                                                                                 4. Special revenue, special assessment obligations, and all non-guaranteed obligations
PHONE NO.                                                                                                                                    5. Railroads
E-MAIL ADDRESS                                                                                          6. Public Utilities
                                                                                                        7. Industrial and Miscellaneous
                                                                                                        8. Banks and Savings and Loan Certificates/Passbooks
                 NAME OF FINANCIAL INSTITUTION WHERE SECURITIES ARE HELD                                9. Preferred Stocks
                       (EITHER STATE TREASURER'S OFFICE/CITIBANK OR                                     10. Cash
                               NAME OF OUTSIDE DEPOSITORY)                                              11. Certificate of Deposit
                                                                                                        12. Letter of Credit
LIST SECURITIES HELD ON DEPOSIT FOR CALIFORNIA WORKERS' COMPENSATION BUSINESS ONLY. UNLESS STATED OTHERWISE, ENTER ALL FIELDS FOR EACH SECURITY.
                                                                                                            FOR SECURITY,
                                                                                           FOR COMMON
                                                                                                          ENTER CUSIP NO.,
   SELECT TYPE OF                                                                         OR PREFERRED                                                                                                                                             (FORMULA)
                                                                                                          FOR CASH, ENTER
SECURITY ACCORDING TO                                                                     STOCK, ENTER                                                                                   AMORTIZED PAR VALUE                                                                  RATING & SOURCE
                           ENTER FULL TITLE OF SECURITY PER TREASURER'S RECEIPT LIST.                          "CASH",       MATURITY DATE INTEREST RATE                                                            MARKET VALUE
 THE LIST LOCATED ON                                                                            "X".                                                           PAR OR FACE VALUE      (IF NOT APPLICABLE, LEAVE                                *DEPOSIT VALUE               (TO COMPLETE, REFER
                                  FOR CD OR LOC, IDENTIFY ISSUING INSTITUTION.                              FOR CD, ENTER     (mm/dd/yyyy)      (%)                                                                  (BID VALUE)
THE TOP RIGHT PORTION                                                                         IF NOT                                                                                            BLANK)                                   (lower of par, amortized par, or       TO Q&A PAGE)
                                                                                                          CERTIFICATE NO.,
     OF THIS PAGE.                                                                          APPLICABLE,                                                                                                                                              market)
                                                                                                           FOR LOC, ENTER
                                                                                           LEAVE BLANK.
                                                                                                               LOC NO.
                                                                                                                                                                                                                                                                            Rating     Source
         (1)                                           (2)                                      (2a)              (3)             (4)              (5)                 (6)                       (7)                      (8)                          (9)                  (10a)       (10b)
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                                                                                                                Page 1 - Subtotal                                 -                                        -                       -                                -
                                                                                                                Page 2 - Subtotal                                 -                                        -                       -                                -
                                                                                                                Page 3 - Subtotal                                 -                                        -                       -                                -
                                                                                                                Page 4 - Subtotal                                 -                                        -                       -                                -
                                                                                                                Page 5 - Subtotal                                 -                                        -                       -                                -
                                                                                                                Page 6 - Subtotal                                 -                                        -                       -                                -
                                                                                                                Page 7 - Subtotal                                 -                                        -                       -                                -
                                                                                                                Page 8 - Subtotal                                 -                                        -                       -                                -
                                                                                                                Page 9 - Subtotal                                 -                                        -                       -                                -
                                                                                                                Page 10 - Subtotal                                -                                        -                       -                                -
                                                                                                                   Grand Total                                    -                                        -                       -                                -
CERTIFICATION: All listed securities are deposited for California workers' compensation business only. None of the Securities listed have been issued by any of our affiliated companies.



NAME                                                                                                      TITLE                                                                      Signature of Authorized Officer of Insurer (BLUE INK)                                           Date Signed
State of California                                                                                                                                                                                                                    DEPARTMENT OF INSURANCE
VALUATIONS OF SECURITIES                                                              Securities which were held on deposit with the State of California under California Insurance Code Section 11691.
FAD A110 (2/11)
                                                                                                       For Col. 1 - Group security items in the following NAIC order and alphabetically within each group:
                                                                                                       1. Governments (including all obligations guaranteed by government)
NAIC NO.               0                                                                               2. States, Territories, and Possessions (Direct & Guaranteed)
COMPANY                                                                                                3. Political Subdivisions of States, Territories, and Possessions (Direct & Guaranteed)
Initial Filing, As of:                                                                                 4. Special revenue, special assessment obligations, and all non-guaranteed obligations
Amended, As of:                                                                                        5. Railroads
Date Amended:                                                                                          6. Public Utilities
                                                                                                       7. Industrial and Miscellaneous
                                                                                                       8. Banks and Savings and Loan Certificates/Passbooks
                                                                                                       9. Preferred Stocks
                                                                                                       10. Cash
                                                                                                       11. Certificate of Deposit
                                                                                                       12. Letter of Credit
LIST SECURITIES HELD ON DEPOSIT FOR CALIFORNIA WORKERS' COMPENSATION BUSINESS ONLY. UNLESS STATED OTHERWISE, ENTER ALL FIELDS FOR EACH SECURITY.
                                                                                                        FOR SECURITY,
                                                                                       FOR COMMON
                                                                                                      ENTER CUSIP NO.,
   SELECT TYPE OF                                                                     OR PREFERRED                                                                                                                              (FORMULA)
                                                                                                      FOR CASH, ENTER
SECURITY ACCORDING TO                                                                 STOCK, ENTER                                       INTEREST                          AMORTIZED PAR VALUE                                                              RATING & SOURCE
                         ENTER FULL TITLE OF SECURITY PER TREASURER'S RECEIPT LIST.                        "CASH",       MATURITY DATE                                                              MARKET VALUE
 THE LIST LOCATED ON                                                                        "X".                                           RATE     PAR OR FACE VALUE   (IF NOT APPLICABLE, LEAVE                             DEPOSIT VALUE               (TO COMPLETE, REFER
                                FOR CD OR LOC, IDENTIFY ISSUING INSTITUTION.                           FOR CD, ENTER      (mm/dd/yyyy)                                                               (BID VALUE)
THE TOP RIGHT PORTION                                                                     IF NOT                                            (%)                                   BLANK)                               (lower of par, amortized par, or       TO Q&A PAGE)
                                                                                                      CERTIFICATE NO.,
     OF THIS PAGE.                                                                      APPLICABLE,                                                                                                                                market)
                                                                                                       FOR LOC, ENTER
                                                                                       LEAVE BLANK.
                                                                                                           LOC NO.
                                                                                                                                                                                                                                                          Rating    Source
         (1)                                         (2)                                   (2a)             (3)               (4)           (5)            (6)                     (7)                   (8)                         (9)                  (10a)      (10b)
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                                                                                                                  Page 2 - Subtotal                                 -                        -                     -                             -
State of California                                                                                                                                                                                                                    DEPARTMENT OF INSURANCE
VALUATIONS OF SECURITIES                                                              Securities which were held on deposit with the State of California under California Insurance Code Section 11691.
FAD A110 (2/11)
                                                                                                       For Col. 1 - Group security items in the following NAIC order and alphabetically within each group:
                                                                                                       1. Governments (including all obligations guaranteed by government)
NAIC NO.               0                                                                               2. States, Territories, and Possessions (Direct & Guaranteed)
COMPANY                                                                                                3. Political Subdivisions of States, Territories, and Possessions (Direct & Guaranteed)
Initial Filing, As of:                                                                                 4. Special revenue, special assessment obligations, and all non-guaranteed obligations
Amended, As of:                                                                                        5. Railroads
Date Amended:                                                                                          6. Public Utilities
                                                                                                       7. Industrial and Miscellaneous
                                                                                                       8. Banks and Savings and Loan Certificates/Passbooks
                                                                                                       9. Preferred Stocks
                                                                                                       10. Cash
                                                                                                       11. Certificate of Deposit
                                                                                                       12. Letter of Credit
LIST SECURITIES HELD ON DEPOSIT FOR CALIFORNIA WORKERS' COMPENSATION BUSINESS ONLY. UNLESS STATED OTHERWISE, ENTER ALL FIELDS FOR EACH SECURITY.
                                                                                                        FOR SECURITY,
                                                                                       FOR COMMON
                                                                                                      ENTER CUSIP NO.,
   SELECT TYPE OF                                                                     OR PREFERRED                                                                                                                              (FORMULA)
                                                                                                      FOR CASH, ENTER
SECURITY ACCORDING TO                                                                 STOCK, ENTER                                       INTEREST                          AMORTIZED PAR VALUE                                                              RATING & SOURCE
                         ENTER FULL TITLE OF SECURITY PER TREASURER'S RECEIPT LIST.                        "CASH",       MATURITY DATE                                                              MARKET VALUE
 THE LIST LOCATED ON                                                                        "X".                                           RATE     PAR OR FACE VALUE   (IF NOT APPLICABLE, LEAVE                             DEPOSIT VALUE               (TO COMPLETE, REFER
                                FOR CD OR LOC, IDENTIFY ISSUING INSTITUTION.                           FOR CD, ENTER      (mm/dd/yyyy)                                                               (BID VALUE)
THE TOP RIGHT PORTION                                                                     IF NOT                                            (%)                                   BLANK)                               (lower of par, amortized par, or       TO Q&A PAGE)
                                                                                                      CERTIFICATE NO.,
     OF THIS PAGE.                                                                      APPLICABLE,                                                                                                                                market)
                                                                                                       FOR LOC, ENTER
                                                                                       LEAVE BLANK.
                                                                                                           LOC NO.
                                                                                                                                                                                                                                                          Rating    Source
         (1)                                         (2)                                   (2a)             (3)               (4)           (5)            (6)                     (7)                   (8)                         (9)                  (10a)      (10b)
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                                                                                                                  Page 3 - Subtotal                                 -                        -                     -                             -
State of California                                                                                                                                                                                                                    DEPARTMENT OF INSURANCE
VALUATIONS OF SECURITIES                                                              Securities which were held on deposit with the State of California under California Insurance Code Section 11691.
FAD A110 (2/11)
                                                                                                       For Col. 1 - Group security items in the following NAIC order and alphabetically within each group:
                                                                                                       1. Governments (including all obligations guaranteed by government)
NAIC NO.               0                                                                               2. States, Territories, and Possessions (Direct & Guaranteed)
COMPANY                                                                                                3. Political Subdivisions of States, Territories, and Possessions (Direct & Guaranteed)
Initial Filing, As of:                                                                                 4. Special revenue, special assessment obligations, and all non-guaranteed obligations
Amended, As of:                                                                                        5. Railroads
Date Amended:                                                                                          6. Public Utilities
                                                                                                       7. Industrial and Miscellaneous
                                                                                                       8. Banks and Savings and Loan Certificates/Passbooks
                                                                                                       9. Preferred Stocks
                                                                                                       10. Cash
                                                                                                       11. Certificate of Deposit
                                                                                                       12. Letter of Credit
LIST SECURITIES HELD ON DEPOSIT FOR CALIFORNIA WORKERS' COMPENSATION BUSINESS ONLY. UNLESS STATED OTHERWISE, ENTER ALL FIELDS FOR EACH SECURITY.
                                                                                                        FOR SECURITY,
                                                                                       FOR COMMON
                                                                                                      ENTER CUSIP NO.,
   SELECT TYPE OF                                                                     OR PREFERRED                                                                                                                              (FORMULA)
                                                                                                      FOR CASH, ENTER
SECURITY ACCORDING TO                                                                 STOCK, ENTER                                       INTEREST                          AMORTIZED PAR VALUE                                                              RATING & SOURCE
                         ENTER FULL TITLE OF SECURITY PER TREASURER'S RECEIPT LIST.                        "CASH",       MATURITY DATE                                                              MARKET VALUE
 THE LIST LOCATED ON                                                                        "X".                                           RATE     PAR OR FACE VALUE   (IF NOT APPLICABLE, LEAVE                             DEPOSIT VALUE               (TO COMPLETE, REFER
                                FOR CD OR LOC, IDENTIFY ISSUING INSTITUTION.                           FOR CD, ENTER      (mm/dd/yyyy)                                                               (BID VALUE)
THE TOP RIGHT PORTION                                                                     IF NOT                                            (%)                                   BLANK)                               (lower of par, amortized par, or       TO Q&A PAGE)
                                                                                                      CERTIFICATE NO.,
     OF THIS PAGE.                                                                      APPLICABLE,                                                                                                                                market)
                                                                                                       FOR LOC, ENTER
                                                                                       LEAVE BLANK.
                                                                                                           LOC NO.
                                                                                                                                                                                                                                                          Rating    Source
         (1)                                         (2)                                   (2a)             (3)               (4)           (5)            (6)                     (7)                   (8)                         (9)                  (10a)      (10b)
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                                                                                                                  Page 4 - Subtotal                                 -                        -                     -                             -
State of California                                                                                                                                                                                                                    DEPARTMENT OF INSURANCE
VALUATIONS OF SECURITIES                                                              Securities which were held on deposit with the State of California under California Insurance Code Section 11691.
FAD A110 (2/11)
                                                                                                       For Col. 1 - Group security items in the following NAIC order and alphabetically within each group:
                                                                                                       1. Governments (including all obligations guaranteed by government)
NAIC NO.               0                                                                               2. States, Territories, and Possessions (Direct & Guaranteed)
COMPANY                                                                                                3. Political Subdivisions of States, Territories, and Possessions (Direct & Guaranteed)
Initial Filing, As of:                                                                                 4. Special revenue, special assessment obligations, and all non-guaranteed obligations
Amended, As of:                                                                                        5. Railroads
Date Amended:                                                                                          6. Public Utilities
                                                                                                       7. Industrial and Miscellaneous
                                                                                                       8. Banks and Savings and Loan Certificates/Passbooks
                                                                                                       9. Preferred Stocks
                                                                                                       10. Cash
                                                                                                       11. Certificate of Deposit
                                                                                                       12. Letter of Credit
LIST SECURITIES HELD ON DEPOSIT FOR CALIFORNIA WORKERS' COMPENSATION BUSINESS ONLY. UNLESS STATED OTHERWISE, ENTER ALL FIELDS FOR EACH SECURITY.
                                                                                                        FOR SECURITY,
                                                                                       FOR COMMON
                                                                                                      ENTER CUSIP NO.,
   SELECT TYPE OF                                                                     OR PREFERRED                                                                                                                              (FORMULA)
                                                                                                      FOR CASH, ENTER
SECURITY ACCORDING TO                                                                 STOCK, ENTER                                       INTEREST                          AMORTIZED PAR VALUE                                                              RATING & SOURCE
                         ENTER FULL TITLE OF SECURITY PER TREASURER'S RECEIPT LIST.                        "CASH",       MATURITY DATE                                                              MARKET VALUE
 THE LIST LOCATED ON                                                                        "X".                                           RATE     PAR OR FACE VALUE   (IF NOT APPLICABLE, LEAVE                             DEPOSIT VALUE               (TO COMPLETE, REFER
                                FOR CD OR LOC, IDENTIFY ISSUING INSTITUTION.                           FOR CD, ENTER      (mm/dd/yyyy)                                                               (BID VALUE)
THE TOP RIGHT PORTION                                                                     IF NOT                                            (%)                                   BLANK)                               (lower of par, amortized par, or       TO Q&A PAGE)
                                                                                                      CERTIFICATE NO.,
     OF THIS PAGE.                                                                      APPLICABLE,                                                                                                                                market)
                                                                                                       FOR LOC, ENTER
                                                                                       LEAVE BLANK.
                                                                                                           LOC NO.
                                                                                                                                                                                                                                                          Rating    Source
         (1)                                         (2)                                   (2a)             (3)               (4)           (5)            (6)                     (7)                   (8)                         (9)                  (10a)      (10b)
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                                                                                                                  Page 5 - Subtotal                                 -                        -                     -                             -
State of California                                                                                                                                                                                                                    DEPARTMENT OF INSURANCE
VALUATIONS OF SECURITIES                                                              Securities which were held on deposit with the State of California under California Insurance Code Section 11691.
FAD A110 (2/11)
                                                                                                       For Col. 1 - Group security items in the following NAIC order and alphabetically within each group:
                                                                                                       1. Governments (including all obligations guaranteed by government)
NAIC NO.               0                                                                               2. States, Territories, and Possessions (Direct & Guaranteed)
COMPANY                                                                                                3. Political Subdivisions of States, Territories, and Possessions (Direct & Guaranteed)
Initial Filing, As of:                                                                                 4. Special revenue, special assessment obligations, and all non-guaranteed obligations
Amended, As of:                                                                                        5. Railroads
Date Amended:                                                                                          6. Public Utilities
                                                                                                       7. Industrial and Miscellaneous
                                                                                                       8. Banks and Savings and Loan Certificates/Passbooks
                                                                                                       9. Preferred Stocks
                                                                                                       10. Cash
                                                                                                       11. Certificate of Deposit
                                                                                                       12. Letter of Credit
LIST SECURITIES HELD ON DEPOSIT FOR CALIFORNIA WORKERS' COMPENSATION BUSINESS ONLY. UNLESS STATED OTHERWISE, ENTER ALL FIELDS FOR EACH SECURITY.
                                                                                                        FOR SECURITY,
                                                                                       FOR COMMON
                                                                                                      ENTER CUSIP NO.,
   SELECT TYPE OF                                                                     OR PREFERRED                                                                                                                              (FORMULA)
                                                                                                      FOR CASH, ENTER
SECURITY ACCORDING TO                                                                 STOCK, ENTER                                       INTEREST                          AMORTIZED PAR VALUE                                                              RATING & SOURCE
                         ENTER FULL TITLE OF SECURITY PER TREASURER'S RECEIPT LIST.                        "CASH",       MATURITY DATE                                                              MARKET VALUE
 THE LIST LOCATED ON                                                                        "X".                                           RATE     PAR OR FACE VALUE   (IF NOT APPLICABLE, LEAVE                             DEPOSIT VALUE               (TO COMPLETE, REFER
                                FOR CD OR LOC, IDENTIFY ISSUING INSTITUTION.                           FOR CD, ENTER      (mm/dd/yyyy)                                                               (BID VALUE)
THE TOP RIGHT PORTION                                                                     IF NOT                                            (%)                                   BLANK)                               (lower of par, amortized par, or       TO Q&A PAGE)
                                                                                                      CERTIFICATE NO.,
     OF THIS PAGE.                                                                      APPLICABLE,                                                                                                                                market)
                                                                                                       FOR LOC, ENTER
                                                                                       LEAVE BLANK.
                                                                                                           LOC NO.
                                                                                                                                                                                                                                                          Rating    Source
         (1)                                         (2)                                   (2a)             (3)               (4)           (5)            (6)                     (7)                   (8)                         (9)                  (10a)      (10b)
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State of California                                                                                                                                                                                                                    DEPARTMENT OF INSURANCE
VALUATIONS OF SECURITIES                                                              Securities which were held on deposit with the State of California under California Insurance Code Section 11691.
FAD A110 (2/11)
                                                                                                       For Col. 1 - Group security items in the following NAIC order and alphabetically within each group:
                                                                                                       1. Governments (including all obligations guaranteed by government)
NAIC NO.               0                                                                               2. States, Territories, and Possessions (Direct & Guaranteed)
COMPANY                                                                                                3. Political Subdivisions of States, Territories, and Possessions (Direct & Guaranteed)
Initial Filing, As of:                                                                                 4. Special revenue, special assessment obligations, and all non-guaranteed obligations
Amended, As of:                                                                                        5. Railroads
Date Amended:                                                                                          6. Public Utilities
                                                                                                       7. Industrial and Miscellaneous
                                                                                                       8. Banks and Savings and Loan Certificates/Passbooks
                                                                                                       9. Preferred Stocks
                                                                                                       10. Cash
                                                                                                       11. Certificate of Deposit
                                                                                                       12. Letter of Credit
LIST SECURITIES HELD ON DEPOSIT FOR CALIFORNIA WORKERS' COMPENSATION BUSINESS ONLY. UNLESS STATED OTHERWISE, ENTER ALL FIELDS FOR EACH SECURITY.
                                                                                                        FOR SECURITY,
                                                                                       FOR COMMON
                                                                                                      ENTER CUSIP NO.,
   SELECT TYPE OF                                                                     OR PREFERRED                                                                                                                              (FORMULA)
                                                                                                      FOR CASH, ENTER
SECURITY ACCORDING TO                                                                 STOCK, ENTER                                       INTEREST                          AMORTIZED PAR VALUE                                                              RATING & SOURCE
                         ENTER FULL TITLE OF SECURITY PER TREASURER'S RECEIPT LIST.                        "CASH",       MATURITY DATE                                                              MARKET VALUE
 THE LIST LOCATED ON                                                                        "X".                                           RATE     PAR OR FACE VALUE   (IF NOT APPLICABLE, LEAVE                             DEPOSIT VALUE               (TO COMPLETE, REFER
                                FOR CD OR LOC, IDENTIFY ISSUING INSTITUTION.                           FOR CD, ENTER      (mm/dd/yyyy)                                                               (BID VALUE)
THE TOP RIGHT PORTION                                                                     IF NOT                                            (%)                                   BLANK)                               (lower of par, amortized par, or       TO Q&A PAGE)
                                                                                                      CERTIFICATE NO.,
     OF THIS PAGE.                                                                      APPLICABLE,                                                                                                                                market)
                                                                                                       FOR LOC, ENTER
                                                                                       LEAVE BLANK.
                                                                                                           LOC NO.
                                                                                                                                                                                                                                                          Rating    Source
         (1)                                         (2)                                   (2a)             (3)               (4)           (5)            (6)                     (7)                   (8)                         (9)                  (10a)      (10b)
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                                                                                                                  Page 7 - Subtotal                                 -                        -                     -                             -
State of California                                                                                                                                                                                                                    DEPARTMENT OF INSURANCE
VALUATIONS OF SECURITIES                                                              Securities which were held on deposit with the State of California under California Insurance Code Section 11691.
FAD A110 (2/11)
                                                                                                       For Col. 1 - Group security items in the following NAIC order and alphabetically within each group:
                                                                                                       1. Governments (including all obligations guaranteed by government)
NAIC NO.               0                                                                               2. States, Territories, and Possessions (Direct Guaranteed)
COMPANY                                                                                                3. Political Subdivisions of States, Territories, and Possessions (Direct & Guaranteed)
Initial Filing, As of:                                                                                 4. Special revenue, special assessment obligations, and all non-guaranteed obligations
Amended, As of:                                                                                        5. Railroads
Date Amended:                                                                                          6. Public Utilities
                                                                                                       7. Industrial and Miscellaneous
                                                                                                       8. Banks and Savings and Loan Certificates/Passbooks
                                                                                                       9. Preferred Stocks
                                                                                                       10. Cash
                                                                                                       11. Certificate of Deposit
                                                                                                       12. Letter of Credit
LIST SECURITIES HELD ON DEPOSIT FOR CALIFORNIA WORKERS' COMPENSATION BUSINESS ONLY. UNLESS STATED OTHERWISE, ENTER ALL FIELDS FOR EACH SECURITY.
                                                                                                        FOR SECURITY,
                                                                                       FOR COMMON
                                                                                                      ENTER CUSIP NO.,
   SELECT TYPE OF                                                                     OR PREFERRED                                                                                                                              (FORMULA)
                                                                                                      FOR CASH, ENTER
SECURITY ACCORDING TO                                                                 STOCK, ENTER                                       INTEREST                          AMORTIZED PAR VALUE                                                              RATING & SOURCE
                         ENTER FULL TITLE OF SECURITY PER TREASURER'S RECEIPT LIST.                        "CASH",       MATURITY DATE                                                              MARKET VALUE
 THE LIST LOCATED ON                                                                        "X".                                           RATE     PAR OR FACE VALUE   (IF NOT APPLICABLE, LEAVE                             DEPOSIT VALUE               (TO COMPLETE, REFER
                                FOR CD OR LOC, IDENTIFY ISSUING INSTITUTION.                           FOR CD, ENTER      (mm/dd/yyyy)                                                               (BID VALUE)
THE TOP RIGHT PORTION                                                                     IF NOT                                            (%)                                   BLANK)                               (lower of par, amortized par, or       TO Q&A PAGE)
                                                                                                      CERTIFICATE NO.,
     OF THIS PAGE.                                                                      APPLICABLE,                                                                                                                                market)
                                                                                                       FOR LOC, ENTER
                                                                                       LEAVE BLANK.
                                                                                                           LOC NO.
                                                                                                                                                                                                                                                          Rating    Source
         (1)                                         (2)                                   (2a)             (3)               (4)           (5)            (6)                     (7)                   (8)                         (9)                  (10a)      (10b)
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                                                                                                                  Page 8 - Subtotal                                 -                        -                     -                             -
State of California                                                                                                                                                                                                                    DEPARTMENT OF INSURANCE
VALUATIONS OF SECURITIES                                                              Securities which were held on deposit with the State of California under California Insurance Code Section 11691.
FAD A110 (2/11)
                                                                                                       For Col. 1 - Group security items in the following NAIC order and alphabetically within each group:
                                                                                                       1. Governments (including all obligations guaranteed by government)
NAIC NO.               0                                                                               2. States, Territories, and Possessions (Direct & Guaranteed)
COMPANY                                                                                                3. Political Subdivisions of States, Territories, and Possessions (Direct & Guaranteed)
Initial Filing, As of:                                                                                 4. Special revenue, special assessment obligations, and all non-guaranteed obligations
Amended, As of:                                                                                        5. Railroads
Date Amended:                                                                                          6. Public Utilities
                                                                                                       7. Industrial and Miscellaneous
                                                                                                       8. Banks and Savings and Loan Certificates/Passbooks
                                                                                                       9. Preferred Stocks
                                                                                                       10. Cash
                                                                                                       11. Certificate of Deposit
                                                                                                       12. Letter of Credit
LIST SECURITIES HELD ON DEPOSIT FOR CALIFORNIA WORKERS' COMPENSATION BUSINESS ONLY. UNLESS STATED OTHERWISE, ENTER ALL FIELDS FOR EACH SECURITY.
                                                                                                        FOR SECURITY,
                                                                                       FOR COMMON
                                                                                                      ENTER CUSIP NO.,
   SELECT TYPE OF                                                                     OR PREFERRED                                                                                                                              (FORMULA)
                                                                                                      FOR CASH, ENTER
SECURITY ACCORDING TO                                                                 STOCK, ENTER                                       INTEREST                          AMORTIZED PAR VALUE                                                              RATING & SOURCE
                         ENTER FULL TITLE OF SECURITY PER TREASURER'S RECEIPT LIST.                        "CASH",       MATURITY DATE                                                              MARKET VALUE
 THE LIST LOCATED ON                                                                        "X".                                           RATE     PAR OR FACE VALUE   (IF NOT APPLICABLE, LEAVE                             DEPOSIT VALUE               (TO COMPLETE, REFER
                                FOR CD OR LOC, IDENTIFY ISSUING INSTITUTION.                           FOR CD, ENTER      (mm/dd/yyyy)                                                               (BID VALUE)
THE TOP RIGHT PORTION                                                                     IF NOT                                            (%)                                   BLANK)                               (lower of par, amortized par, or       TO Q&A PAGE)
                                                                                                      CERTIFICATE NO.,
     OF THIS PAGE.                                                                      APPLICABLE,                                                                                                                                market)
                                                                                                       FOR LOC, ENTER
                                                                                       LEAVE BLANK.
                                                                                                           LOC NO.
                                                                                                                                                                                                                                                          Rating    Source
         (1)                                         (2)                                   (2a)             (3)               (4)           (5)            (6)                     (7)                   (8)                         (9)                  (10a)      (10b)
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                                                                                                                  Page 9 - Subtotal                                 -                        -                     -                             -
State of California                                                                                                                                                                                                                    DEPARTMENT OF INSURANCE
VALUATIONS OF SECURITIES                                                              Securities which were held on deposit with the State of California under California Insurance Code Section 11691.
FAD A110 (2/11)
                                                                                                       For Col. 1 - Group security items in the following NAIC order and alphabetically within each group:
                                                                                                       1. Governments (including all obligations guaranteed by government)
NAIC NO.               0                                                                               2. States, Territories, and Possessions (Direct & Guaranteed)
COMPANY                                                                                                3. Political Subdivisions of States, Territories, and Possessions (Direct & Guaranteed)
Initial Filing, As of:                                                                                 4. Special revenue, special assessment obligations, and all non-guaranteed obligations
Amended, As of:                                                                                        5. Railroads
Date Amended:                                                                                          6. Public Utilities
                                                                                                       7. Industrial and Miscellaneous
                                                                                                       8. Banks and Savings and Loan Certificates/Passbooks
                                                                                                       9. Preferred Stocks
                                                                                                       10. Cash
                                                                                                       11. Certificate of Deposit
                                                                                                       12. Letter of Credit
LIST SECURITIES HELD ON DEPOSIT FOR CALIFORNIA WORKERS' COMPENSATION BUSINESS ONLY. UNLESS STATED OTHERWISE, ENTER ALL FIELDS FOR EACH SECURITY.
                                                                                                        FOR SECURITY,
                                                                                       FOR COMMON
                                                                                                      ENTER CUSIP NO.,
   SELECT TYPE OF                                                                     OR PREFERRED                                                                                                                              (FORMULA)
                                                                                                      FOR CASH, ENTER
SECURITY ACCORDING TO                                                                 STOCK, ENTER                                       INTEREST                          AMORTIZED PAR VALUE                                                              RATING & SOURCE
                         ENTER FULL TITLE OF SECURITY PER TREASURER'S RECEIPT LIST.                        "CASH",       MATURITY DATE                                                              MARKET VALUE
 THE LIST LOCATED ON                                                                        "X".                                           RATE     PAR OR FACE VALUE   (IF NOT APPLICABLE, LEAVE                             DEPOSIT VALUE               (TO COMPLETE, REFER
                                FOR CD OR LOC, IDENTIFY ISSUING INSTITUTION.                           FOR CD, ENTER      (mm/dd/yyyy)                                                               (BID VALUE)
THE TOP RIGHT PORTION                                                                     IF NOT                                            (%)                                   BLANK)                               (lower of par, amortized par, or       TO Q&A PAGE)
                                                                                                      CERTIFICATE NO.,
     OF THIS PAGE.                                                                      APPLICABLE,                                                                                                                                market)
                                                                                                       FOR LOC, ENTER
                                                                                       LEAVE BLANK.
                                                                                                           LOC NO.
                                                                                                                                                                                                                                                          Rating    Source
         (1)                                         (2)                                   (2a)             (3)               (4)           (5)            (6)                     (7)                   (8)                         (9)                  (10a)      (10b)
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State of California
VALUATIONS OF SECURITIES
FAD A110 (2/11)


           WHEN ALL SECURITIES ARE ENTERED, PLEASE PRINT THIS PAGE AND COMPLETE BY HAND.

  Securities which are held on deposit with the State of California under California Insurance Code Section 11691.
                                          Certification (Notarization) Page

Form A-110 filed for (Check one):          December 31, 2010             December 31, 2010 Amended           Date Amended
                                           March 31, 2011                March 31, 2011 Amended              Date Amended

In the account of:                                                       NAIC No:                NAIC Group No:

FOR DEPOSITS HELD WITH THE STATE TREASURER'S OFFICE (CITIBANK), COMPLETE THIS SECTION ONLY.

     I, ______________________ do hereby certify under penalty of perjury that I am an officer of the company; that I am
     competent to appraise and report the market value of the herein described securities; and that the individual market
     value shown on the herein Valuation of Securities Schedule totaling $______________________ (page 1, col. 8, grand
     total) in Market Value, consisting of ______ page(s) for the securities listed thereon, are the same as that reported on
     the CitiBank statement as of the date stated herein.


     Signature                                              Date Signed


     Print Name                                             Title


     Street Address                                         City, State & Zip Code


     Certificate of acknowledgement to be made before a Notary Public State of ______________________, County of
     ______________________ as: On this ______ of ______________________, 2011 personally appeared before me,
     ______________________ personally known to me to be the person who signed the above Certificate and
     acknowledged to me that he/she executed the same. In witness whereof, I have hereunto set my hand and affixed my
     official seal on the date written above.




     Notary Public in and for said County and State         My Commission Expires on              (Notary Seal)

FOR DEPOSITS HELD AT AN AUTHORIZED OFFSITE DEPOSITORY, COMPLETE THIS SECTION ONLY.

     I, ______________________ do hereby certify under penalty of perjury that I am a Bank Securities Officer or an
     experienced, reputable investment securities analyst or counselor in good standing and am competent to appraise and
     report the market value of the herein described securities; that I am not an Officer, Director, Trustee or salaried
     employee of the named insurer and have no financial interest in it; that in my opinion, based on the best evidence
     customarily resorted to by appraisers under similar circumstances the individual market value shown on the herein
     Valuation of Securities Schedule totaling $______________________ (page 1, col. 8, grand total) in Market Value,
     consisting of ______ page(s) for the securities listed thereon, are the fair market value thereof as of the date stated
     herein.


     Signature                                              Date Signed


     Print Name                                             Title                                 Company's Affiliation


     Street Address                                         City, State & Zip Code


     Certificate of acknowledgement to be made before a Notary Public State of ______________________, County of
     ______________________ as: On this ______ of ______________________, 2011 personally appeared before me,
     ______________________ personally known to me to be the person who signed the above Certificate and
     acknowledged to me that he/she executed the same. In witness whereof, I have hereunto set my hand and affixed my
     official seal on the date written above.




     Notary Public in and for said County and State         My Commission Expires on              (Notary Seal)




                                                         Certification
State of California


County of


On                             before me,
            Date                                        Here Insert Name and Title of the Officer

personally appeared
                                                  Name(s) of Signor(s)




                                            who proved to me on the basis of satisfactory
                                            evidence to be the person(s) whose name(s) is/are
                                            subscribed to the within instrument and acknowledged
                                            to me that he/she/they executed the same in
                                            his/her/their authorized capacity(ies), and that by
                                            his/her/their signature(s) on the instrument the
                                            person(s), or the entity upon behalf of which the
                                            person(s) acted, executed the instrument.

                                            I certify under PENALTY OF PERJURY under the
                                            laws of the State of California that the foregoing
                                            paragraph is true and correct.

                                            WITNESS my hand and official seal.

     Place Notary Seal Above                Signature
                                                              Signature of Notary Public
State of California
VALUATIONS OF SECURITIES
FAD A110 (2/11)

             Q&A: Answers to commonly asked questions regarding the Form A110

 1   Who has to file a Form A110 with the California Department of Insurance?
         Insurers licensed to transact workers' compensation insurance in California or
         reinsurers authorized to reinsure the injury, disablement, or death portions of policies of workers'
         compensation insurance under the class of disability insurance.
 2   When do I file and how often?
         The filing is required at least twice a year.*
         Form A110 as of December 31st is due the following March 1.
         Form A110 as of March 31st is due the following May 15.
         *The Department may request any insurer or reinsurer to make additional filings when necessary.
 3   Do we list all securities (bonds, preferred or common stocks) and other forms of deposit given as
     collateral for general and/or workers’ compensation deposits on the Form A110?

         NO, only securities (or other forms of deposit such as cash, certificate of deposit and letter of credit) on
         deposit for the purpose of CA workers’ compensation shall be listed on the Form A110.

         If any securities for general purpose are mistakenly listed on the Form A110, you shall remove such securities
         from the Form A110 and file an amendment immediately. Include with your amended filing a detailed
         summary explaining which securities were removed or changed.

         Note: Late fees are calculated based on the deposits held for CA workers' compensation only. It is therefore
         critical that you complete this form accurately.

 4   Where can I find the regulation regarding securities eligible for deposit?
         The California Code of Regulations - "§2509.5. Classes of Securities Eligible for Deposit" can be found on the
         internet at http://www.calregs.com

 5   What are the Debt Security Rating and Listing Requirements?
         Please refer to the California Code of Regulations - "§2509.8. Debt Security Rating and Listing Requirements"
         at http://www.calregs.com

         For Cash, Certificates of Deposits, or Letters of Credit: Rating = AAA, Source = NA
         For U.S. Treasuries Bonds or Notes: Rating = AAA, Source = NA
 6   Form A110 requires signature from an appropriate officer of an insurer on the first page of the form. Do we
     need to complete the certification page as well?

         Yes
         .
         For deposits with the State Treasurer's Office (STO)/Citibank:
              ∙ Fill-out the top portion of the Certification Page.
              ∙ An appropriate officer of the company may sign.
              ∙ Notarization must be done on the top portion of the Certification Page.
              ∙ If the Notary is a California Notary, the CA Notary Page must be used.

         For deposits with approved institutions other than (STO)/Citibank:
              ∙ Fill-out the bottom portion of the Certification Page.
              ∙ Signature must come from the custodian bank which physically holds either debt or equity
                securities for workers' compensation deposits.
              . Notarization must be done on the bottom portion of the Certification Page.
              . If the Notary is a California Notary, the CA Notary Page must be used.

 7   How do we complete Form A110 if we have LOCs, Cash, and/or CDs only?
         For certificate of deposit or letter of credit, each insurer shall obtain certification from the issuing bank of
         those financial instruments. See also Instructions Page, item 5 LOC Instructions.

         For cash, the insurer shall procure the certification from the custodian bank.

 8   What is Amortized Par Value (Column 7)?
         Amortized Par Value is the current face value of the instrument reported. If the instrument has a built in
         declining face value due to the nature of the issue, the Department may not accept such instrument for
         Workers' Compensation deposit purpose because declining face value can cause the overall deposit to fall
         below its required deposit.




                                                            Q&A
State of California                                                                                  DEPARTMENT OF INSURANCE
VALUATIONS OF SECURITIES
FAD A110 (2/11)


 Part 1 If your company name does not appear on page 1, enter your company info below.
                                                                                                                      NAIC
 NAIC                                                                                                                 Group      Dom.
  No.                                                 Filing Company Name                                              No.       State




                                                                          A
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Description: Notary Public Certificate of Acknowledgement document sample