County Mutual Abstract of Statement

County Mutual Abstract of Statement

SFN 4805
Company Name*
City and State*

CityState
Designated Newspaper*
For Year Ending December 31, 20__*

MonthDayYear
Date
Data to Report

Please drop all cents
Total Admitted Assets   *   Page 3, Line 29
Total Amount of All Liabilities   *   Page 3, Line 42
Surplus As Regards Policyholders   *   Page 3, Line 43
Total Income   *   Page 2, Line 13
Total Disbursements   *   Page 2, Line 43
North Dakota Business Only
Net Premiums Received * Page 2, Line 1(e)
Net Losses Paid * Page 2, Line 19
Name of Person Completing From *

NameTitle
Phone Number
Please enter a valid phone number.
Email*
example@example.com
Should be Empty:

Data to Report