INS - Abstract of Statement - SFN 4802

Abstract of Statement
North Dakota Insurance Department
SFN 4802
Select Your Company Type*
Is this an amendment?*

YesNo
NAIC Company Code*
(Enter the company code and tab out. This will automatically populate Name and State of Domicile.)
Name of Company*
State of Domicile*
For Year Ending December 31, 20*
DATA FROM ANNUAL STATEMENT OF COMPANY
TOTAL ASSETS*
(Page 2)
TOTAL LIABILITIES*
(Page 3)
Aggregate write-ins for special surplus funds*
Common Capital Stock *
(Page 3)
Preferred Capital Stock *
(Page 3)
Aggregate Write-ins for Other Than Special Surplus Funds *
(Page 3)
Surplus Notes *
(Page 3)
Gross Paid in and Contributed Surplus *
(Page 3)
Unassigned Funds*
(Page 3)
Less Treasury Stock, at Cost*
(Page 3)
TOTAL CAPITAL AND SURPLUS
TOTAL LIABILITIES, CAPITAL AND SURPLUS

NORTH DAKOTA BUSINESS ONLY
North Dakota Title Companies
Source of Data from Schedule T, Line 35
Total Direct Premiums Earned (column 6)*
Total Direct Losses Incurred (column 8)*
North Dakota Life Companies
Total Life and Annuity Premiums Written (Line 5)*
Total Life and Annuity Direct Losses Paid (Line 15)*
Total Accident and Health Direct Premiums Written (Line 26)*
Total Accident and Health Direct Losses Paid (Line 26)*
North Dakota Health Companies
Accident and Health
Total Premiums Earned (Line 13)*
Total Amount Incurred (Line 15)*
Property and Casualty Companies
From State Page
Total Direct Premiums Earned*
Total Direct Losses Incurred*
Total Accident and Health Direct Premiums Earned (Line 13-15.6)*
Total Accident and Health Direct Losses Incurred (Line 13-15.6)*

Name of Person Completing the Form*
Telephone Number*
Prefer toll-free (if available)
Title*
Email Address*
example@example.com
Division and/or Department*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
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