The following form is to be used in making reports of multiple policies in accordance with the requirements of Regulation .17 of this chapter: (a)3 (b)4 (c) (d) (e) (f) (g) (h) (i) (j) (o)5 Year Earned Premium Factor (b) × (c) CumulativeLoss Ratio (d) × (e) Factor (b) × (g) CumulativeLoss Ratio (h) × (i) Policy YearLoss Ratio 1 2.770 0.442 0.000 0.000 0.4 2 4.175 0.493 0.000 0.000 0.55 3 4.175 0.493 1.194 0.659 0.65 4 4.175 0.493 2.245 0.669 0.67 5 4.175 0.493 3.170 0.678 0.69 6 4.175 0.493 3.998 0.686 0.71 7 4.175 0.493 4.754 0.695 0.73 8 4.175 0.493 5.445 0.702 0.75 9 4.175 0.493 6.075 0.708 0.76 10 4.175 0.493 6.650 0.713 0.76 11 4.175 0.493 7.176 0.717 0.76 12 4.175 0.493 7.655 0.720 0.77 13 4.175 0.493 8.093 0.723 0.77 14 4.175 0.493 8.493 0.725 0.77 15+6 4.175 0.493 8.684 0.725 0.77 ________ ________ ________ ________ Total: (k): (l): (m): (n): The purpose of this form is to report the following information on each resident of this state who has in force more than one Medicare supplement policy or certificate. The information is to be grouped by individual policyholder. FORM FOR REPORTINGMEDICARE SUPPLEMENT POLICIES Company name: ________________________________________ Address: ________________________________________ ________________________________________ Phone Number: ________________________________________ Due: March 1, annually Policy andCertificate # Date ofIssuance