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: