Exhibit E - Supplement A to Schedule T Reconciliation Form

Current through Register Vol. 46, No. 15, April 8, 2022

SCHEDULE T DATA RECONCILIATION FORM

Company Name:

Line Number

Line

Loss paid - number of claims

Losses paid - dollar amount

1

Schedule T, Supplement A

2

Part 928 claim report totals

3

Difference (line 1 - line 2)

Adjustments to Schedule T

4

Sch T - payments reported in current year on claims closed in prior years

5

Sch T - claims not reported in Part 928 claims data for other reasons (claim not reportable in this State, etc.; specify in separate explanation)

6

Correction for other discrepancies (occurrence vs. claims reporting, other accounting issues, etc.; specify in separate explanation)

7

Adjustments to Schedule T (line 1 - line 4 - line 5 - line 6)

Adjustments to 928 Claims Data

8

Claims not reported on Schedule T for other reasons (reported for another state, etc.; specify in separate explanation)

9

Other adjustments needed for claims data to reconcile to Schedule T

10

Adjustments to claims data (line 2 - line 8 - line 9)

Reconciled Amounts

11

Difference in adjusted amounts (line 7 - line 10) - this line should equal 0.

Explanation for adjustments on line 5:

Explanation for adjustments on line 6:

Explanation for adjustments on line 8:

Explanation for adjustments on line 9:

Notes

Added at 36 Ill. Reg. 18677, effective December 17, 2012 Amended at 40 Ill. Reg. 16137, effective 11/30/2016

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