(1) This is the appendix referred to in ARM 6.6.508(2) and (3) .

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MEDICARE SUPPLEMENT REFUND CALCULATION FORM

FOR CALENDAR YEAR ______

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TYPE¹ _____________________________ SMSBP² _________________________

For the State of ______________________ Company Name ____________________

NAIC Group Code ____________________�NAIC Company Code ________________

Address ___________________________ �Person Completing Exhibit ____________

Title _______________________________ Telephone Number __________________

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Line	�	(a) Earned Premium3	(b) Incurred Claims4
1.	Current Year's Experience	�	�
�	a.� Total (all policy years)	�	�
�	b.� Current year's issues5	�	�
�	c.� Net (for reporting ��� purposes - 1a-1b	�	�
2.	Past Year's Experience (all policy years)	�	�
3.	Total Experience (Net Current Year + Past Year)	�	�
4.	Refunds Last year (Excluding Interest)		�
5.	Previous Since Inception (Excluding Interest)		�
6.	Refunds Since Inception (Excluding Interest)		�
7.	Benchmark Ratio Since Inception (see worksheet for Ratio 1)		�
8.	Experienced Ratio Since Inception (Ratio 2) �Total Actual Incurred Claims (line 3, col. �b) �Total Earned Premium (line 3, col. a) - �Refunds Since Inception (line 6)		�
9.	Life Years Exposed Since Inception If the Experienced Ratio is less than the Benchmark Ratio, and there are more than 500 life years exposure, then proceed to calculation of refund		�
10.	Tolerance Permitted (obtained from credibility table)		�

Medicare Supplement Credibility Table

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Life Years Exposed �Since Inception Tolerance
10,000+	0.0%
5,000-9,999	5.0%
2,500-4,999	7.5%
1,000-2,499	10.0%
500-999	15.0%
If less than 500, no credibility.

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1. Individual, Group, Individual Medicare Select, or Group Medicare Select Only.
2. "SMSBP" = Standardized Medicare Supplement Benefit Plan - Use "P" for prestandardized plans.
3. Includes Modal Loadings and Fees Charged
4. Excludes Active Life Reserves
5. This is to be used as "Issue Year Earned Premium" for Year 1 of next year's "Worksheet for Calculation of Benchmark Ratios"

11.	Adjustment to Incurred Claims for Credibility Ratio 3 = Ratio 2 + Tolerance

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If Ratio 3 is more than Benchmark Ratio (Ratio 1) , a refund or credit to premium is not required.

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If Ratio 3 is less than the Benchmark Ratio, then proceed.

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12.	Adjusted Incurred Claims [Total Earned Premium (line 3, col. a) - Refunds Since Inception (line 6) ] x Ratio 3 (line 11)
13.	Refund = Total Earned Premiums (line 3, col. a) - Refunds Since Inception (line 6) -[Adjusted Incurred Claims (line 12) /Benchmark Ratio (Ratio 1) ]

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If the amount on line 13 is less than .005 times the annualized premium in force as of December 31 of the reporting year, then no refund is made.� Otherwise, the amount on line 13 is to be refunded or credited, and a description of the refund or credit against premiums to be used must be attached to this form.

I certify that the above information and calculations are true and accurate to the best of my knowledge and belief.

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����������������������� ___________________________________

�������������������������������������� Signature

����������������������� ___________________________________

�������������������������������������� Name - Please Type

����������������������� ___________________________________

�������������������������������������� Title - Please Type

����������������������� ___________________________________

�������������������������������������� Date

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REPORTING FORM FOR THE CALCULATION OF BENCHMARK RATIO SINCE INCEPTION FOR GROUP POLICIES

FOR CALENDAR YEAR ____________

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����������������� TYPE¹ ________________________________��� SMSBP² _____________________________

����������������� For the State of �� _________________���� Company Name _______________________

����������������� NAIC Group Code _____________________���� NAIC Company Code___________________

����������������� Address _____________________________���� Person Completing Exhibit___________

����������������� Title _______________________________���� Telephone Number ___________________

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(a)3	(b)4	(c)	(d)	(e)	(f)	(g)	(h)	(i)	(j)	(o)5
� Year	Earned Premium	� Factor	� (b)x(c)	Cumulative Loss Ratio	� (d)x(e)	� Factor	� (b)x(g)	Cumulative Loss Ratio	� (h)x(i)	Policy Year Loss Ratio
1	�	2.770	�	0.507	�	0.000	�	0.000	�	0.46
2	�	4.175	�	0.567	�	0.000	�	0.000	�	0.63
3	�	4.175	�	0.567	�	1.194	�	0.759	�	0.75
4	�	4.175	�	0.567	�	2.245	�	0.771	�	0.77
5	�	4.175	�	0.567	�	3.170	�	0.782	�	0.80
6	�	4.175	�	0.567	�	3.998	�	0.792	�	0.82
7	�	4.175	�	0.567	�	4.754	�	0.802	�	0.84
8	�	4.175	�	0.567	�	5.445	�	0.811	�	0.87
9	�	4.175	�	0.567	�	6.075	�	0.818	�	0.88
10	�	4.175	�	0.567	�	6.650	�	0.824	�	0.88
11	�	4.175	�	0.567	�	7.176	�	0.828	�	0.88
12	�	4.175	�	0.567	�	7.655	�	0.831	�	0.88
13	�	4.175	�	0.567	�	8.093	�	0.834	�	0.89
14	�	4.175	�	0.567	�	8.493	�	0.837	�	0.89
15+6	�	4.175	�	0.567	�	8.684	�	0.838	�	0.89
Total	�	�	(k):	�	(l):	�	(m):	�	(n):	�

Benchmark Ratio Since Inception (1 + n)/(k + m): ____________

¹Individual, Group, Individual Medicare Select, or Group Medicare Select Only.

² "SMSBP" = Standardized Medicare Supplement Benefit Plan - Use "P" for pre-standardized plans

³ Year 1 is the current calendar year - 1.�Year 2 is the current calendar year - 2 (etc). (Example: If the current year is 1991, then: Year 1 is 1990; Year 2 is 1989, etc.)

⁴ For the calendar year on the appropriate line in column (a), the premium earned during that year for policies issued in that year.

⁵ These loss ratios are not explicitly used in computing the benchmark loss ratios.�They are the loss ratios, on a policy year basis, which result in the cumulative loss ratios displayed on this worksheet.�They are shown here for informational purposes only.

⁶ To include the earned premium for all years prior to as well as the 15th year prior to the current year.

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REPORTING FORM FOR THE CALCULATION OF BENCHMARK RATIO SINCE INCEPTION FOR INDIVIDUAL POLICIES

FOR CALENDAR YEAR ____________

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����������������� TYPE¹ ______________________________�SMSBP² _____________________________

����������������� For the State of ___________________ Company Name _______________________

����������������� NAIC Group Code ____________________ NAIC Company Code __________________

����������������� Address ____________________________�Person Completing Exhibit __________

����������������� Title ______________________________�Telephone Number ___________________

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(a)3	(b)4	(c)	(d)	(e)	(f)	(g)	(h)	(i)	(j)	(o)5
� Year	Earned Premium	� Factor	� (b)x(c)	Cumulative Loss Ratio	� (d)x(e)	� Factor	� (b)x(g)	Cumulative Loss Ratio	� (h)x(i)	Policy Year Loss Ratio
1	�	2.770	�	0.442	�	0.000	�	0.000	�	0.40
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):	�

Benchmark Ratio Since Inception (1 + n)/(k + m): ____________

¹Individual, Group, Individual Medicare Select, or Group Medicare Select Only.

² "SMSBP" = Standardized Medicare Supplement Benefit Plan - Use "P" for pre-standardized plans

³ Year 1 is the current calendar year - 1.�Year 2 is the current calendar year - 2 (etc). (Example: If the current year is 1991, then: Year 1 is 1990; Year 2 is 1989, etc.)

⁴ For the calendar year on the appropriate line in column (a), the premium earned during that year for policies issued in that year.

⁵ These loss ratios are not explicitly used in computing the benchmark loss ratios.�They are the loss ratios, on a policy year basis, which result in the cumulative loss ratios displayed on this worksheet.�They are shown here for informational purposes only.

⁶ To include the earned premium for all years prior to as well as the 15th year prior to the current year.