ࡱ> 58234O -bjbjr9r9 "SWiSWi#   $P Q@lLPPP???????$BsE??PP4 @ LPP? ? 9,<PpVQL:?!@0Q@:FF4,<F,< ??Q@F X R: ANNUAL STATEMENT BLANK LIFE/FRATERNAL VM-22 RESERVES SUPPLEMENT PART 1A Non-Variable Annuity Insurance Reserves Valued According to VM-22 by Product Type For The Year Ended December 31, 20__ (To Be Filed by March 1) Prior YearCurrent Year1 Reported Reserve in Excess of Cash Surrender Value2 Reported Reserve in Excess of Cash Surrender Value 1. Post-Reinsurance-Ceded Reserve 1.1. Fixed Annuities Deferred without Guaranteed Living Benefit    1.2. Indexed Annuities Deferred without Guaranteed Living Benefit    1.3. Individual Immediate and Deferred Income Annuities and Annuitizations    1.4. Structured Settlements    1.5. Pension Risk Transfer and Group Payout Annuities and Annuitizations    1.6. Longevity Reinsurance    1.7. Fixed Annuities Deferred with Guaranteed Living Benefit    1.8. Indexed Annuities Deferred with Guaranteed Living Benefit    1.9. Aggregate Write-Ins for Other Products  2. Total Post-Reinsurance-Ceded Reserve (Sum of Lines 1.1 through 1.9) 3. Pre-Reinsurance-Ceded Reserve  3.1. Fixed Annuities Deferred without Guaranteed Living Benefit    3.2. Indexed Annuities Deferred without Guaranteed Living Benefit    3.3. Individual Immediate and Deferred Income Annuities and Annuitizations    3.4. Structured Settlements    3.5. Pension Risk Transfer and Group Payout Annuities and Annuitizations    3.6. Longevity Reinsurance    3.7. Fixed Annuities Deferred with Guaranteed Living Benefit    3.8. Indexed Annuities Deferred with Guaranteed Living Benefit    3.9. Aggregate Write-Ins for Other Products  4. Total Pre-Reinsurance-Ceded Reserve (Sum of Lines 3.1 through 3.9) 5. Total Reserves Ceded (Line 4 minus Line 2)DETAILS OF WRITE-INS1.901. .   1.902.   1.903.   1.998. Summary of remaining write-ins for Line 1.9 from overflow page   1.999 Totals (Lines 1.901 through 1.903 plus 1.998) (Line 1.9 above)3.901. .   3.902.   3.903.   3.998. Summary of remaining write-ins for Line 3.9 from overflow page   3.999 Totals (Lines 3.901 through 3.903 plus 3.998) (Line 3.9 above) VM-22 RESERVES SUPPLEMENT PART 1B Non-Variable Annuity Reserves Valued According to VM-22 by Product Type For The Year Ended December 31, 20__ (To Be Filed by March 1) Current YearSECTION ASECTION BSECTION C12345678910111213141516Cash Surrender ValuePrescribed Projection AmountCTE70 (adjusted)Buffer Amount2Additional Standard Projection AmountStochastic ReserveNumber of ContractsCash Surrender ValuePrescribed Projection AmountBuffer Amount3Additional Standard Projection AmountDeterministic Reserve Number of Contracts Cash Surrender ValueVM-A, VM-C, and VM-V Reserve Number of Contracts 1. Post-Reinsurance-Ceded Reserve 1.1. Fixed Annuities Deferred without Guaranteed Living Benefit       XXX     XXXXXXXXXXXX 1.2. Indexed Annuities Deferred without Guaranteed Living Benefit       XXX     XXX  XXX 1.3. Individual Immediate and Deferred Income Annuities and Annuitizations       XXX     XXX  XXX 1.4. Structured Settlements       XXX     XXX  XXX 1.5. Pension Risk Transfer and Group Payout Annuities and Annuitizations       XXX     XXX  XXX 1.6. Longevity Reinsurance       XXX     XXX  XXX 1.7. Fixed Annuities Deferred with Guaranteed Living Benefit       XXX     XXX  XXX 1.8. Indexed Annuities Deferred with Guaranteed Living Benefit       XXX     XXX  XXX 1.9. Aggregate Write-Ins for Other Products XXXXXXXXX 2. Total Post-Reinsurance-Ceded Reserve (Sum of Lines 1.1 through 1.9)XXXXXXXXX 3. Pre-Reinsurance-Ceded Reserve  3.1. Fixed Annuities Deferred without Guaranteed Living Benefit              XXXXXX  3.2. Indexed Annuities Deferred without Guaranteed Living Benefit                  3.3. Individual Immediate and Deferred Income Annuities and Annuitizations                  3.4. Structured Settlements                  3.5. Pension Risk Transfer and Group Payout Annuities and Annuitizations                  3.6. Longevity Reinsurance                  3.7. Fixed Annuities Deferred with Guaranteed Living Benefit                  3.8. Indexed Annuities Deferred with Guaranteed Living Benefit                  3.9. Aggregate Write-Ins for Other Products  4. Total Pre-Reinsurance-Ceded Reserve (Sum of Lines 3.1 through 3.9) 5. Total Reserves Ceded (Line 4 minus Line 2)XXXXXXXXXDETAILS OF WRITE-INS1.901. .       XXX     XXX  XXX1.902.       XXX     XXX  XXX1.903.       XXX     XXX  XXX1.998. Summary of remaining write-ins for Line 1.9 from overflow page      XXX     XXX  XXX1.999 Totals (Lines 1.901 through 1.903 plus 1.998) (Line 1.9 above)XXXXXXXXX3.901. .                 3.902.                 3.903.                 3.998. Summary of remaining write-ins for Line 3.9 from overflow page                3.999 Totals (Lines 3.901 through 3.903 plus 3.998) (Line 3.9 above) 2 Equal to the Unfloored CTE70 (adjusted) minus Unfloored CTE65 (adjusted) 3 Equal to the Unfloored DR minus Unfloored scenario reserve calibrated to CTE65 VM-22 RESERVES SUPPLEMENT PART 2 Non-Variable Annuity PBR Exemption For The Year Ended December 31, 20__ (To Be Filed by March 1) Non-Variable Annuity PBR Exemption as defined in the оٷ adopted Valuation Manual (VM) 1. Has the company filed and been granted a Non-Variable Annuity PBR Exemption from the reserve requirements of VM-22 of the Valuation Manual by their state of domicile? Yes [ ] No [ ] 2. If the response to Question 1 is "Yes", then check the source of the granted Non-Variable Annuity PBR Exemption definition? (Check either 2.1, 2.2 or 2.3) 2.1 оٷ Adopted VM [ ] 2.2 State Statute (SVL) [ ] Complete items a and b, as appropriate. a. Is the criteria in the State Statute (SVL) different from the оٷ adopted VM? Yes [ ] No [ ] b. If the answer to a above is Yes, provide the criteria the state has used to grant the Non-Variable Annuity PBR Exemption (e.g., Group/Legal Entity criteria) and the minimum reserve requirements that are required by the state of domicile (if the minimum reserve requirements are the same as the Adopted VM, write SAME AS оٷ VM: 2.3 State Regulation [ ] Complete items a and b, as appropriate. a. Is the criteria in the State Regulation different from the оٷ adopted VM? Yes [ ] No [ ] b. If the answer to a above is Yes, provide the criteria the state has used to grant the Non-Variable Annuity PBR Exemption (e.g., Group/Legal Entity criteria) and the minimum reserve requirements that are required by the state of domicile (if the minimum reserve requirements are the same as the Adopted VM, write SAME AS оٷ VM:  VM-22 RESERVES SUPPLEMENT PART 3 Other Exclusions from Non-Variable Annuity PBR For The Year Ended December 31, 20__ (To Be Filed by March 1) 1A. Has the company filed and been granted a Single State Exemption from the reserve requirements of VM-22 of the Valuation Manual by their state of domicile? Yes [ ] No [ ] 1B. If the answer to question 1A is Yes please discuss any business not covered under the Single State Exemption. ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ 2A. If the answer to question 1A is "Yes", does the company have risks for policies issued outside its state of domicile? Yes [ ] No [ ] 2B. If the answer to question 2A is Yes please discuss the risks for policies issued outside the state of domicile, how those risks came to be a responsibility of the company, and why the company would still be considered a Single State Company with such risks. ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ Is all of the companys non-variable annuity business excluded from the requirements of VM-22 pursuant to Section II, Subsection 2 of the Valuation Manual? Yes [ ] No [ ]   FILENAME \p \* MERGEFORMAT W:\QA\BlanksProposals\2020-11BWG.doc This page intentionally left blank.  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