19 Miss. Code. R. 2-11.07 - Experience Refund Agreement- Exhibit B

EXPERIENCE REFUND AGREEMENT

1. Net written premiums _______________________

2. Premium Reserves - beginning of period _______________________

3. Premium Reserves - end of period _______________________

4. Earned premiums [1+2-3] _______________________

5. Claims paid _______________________

6. Claims due and unpaid and in course of settlement - Beginning of period _______________________

7. Claims due and unpaid and in course of settlement - End of period _______________________

8. Claims incurred but not reported - beginning of period _______________________

9. Claims incurred but not reported - end of period _______________________

10. Present value of claims not yet due - beginning of period _______________________

11. Present value of claims not yet due - end of period _______________________

12. Incurred claims [5-6+7-8+9-10+11] _______________________

13. Premium taxes paid _______________________

14. Premium taxes due and unpaid - beginning of period _______________________

15. Premium taxes due and unpaid - end of period _______________________

16. Earned premium taxes [13-14+15] _______________________

17. Compensation paid or earned during period _______________________

18. Expenses Incurred _______________________

19. Experience refund receivable from prior year _______________________

20. UNDERWRITING PROFIT DUE [4-12-16-17-18-19] _______________________

21. Percentage due Agent _______________________

22. EXPERIENCE REFUND DUE [20x11] _______________________

Notes

19 Miss. Code. R. 2-11.07

Miss. Code Ann. § 83-53-29 (Supp. 2014)

Amended 12/25/2014