r Application Form and Supporting Documents

Transcription

1 r Application Form and Supporting Documents

2 Applicant Name: Symetra Life Insurance Company NAIC No FEIN: Item l -Application Form The following documents are submitted as Item l of the Application: Exhibit 1-A Exhibit 1-B Exhibit l-c Primary Application Checklist (Fonn I P) /' 1 Original UCAA Primary Application (Fonn 2P) Lines oflnsurance (Fonn 3) /

3 SYMETRA LIFE INSURANCE COMPANY PRIMARY APPLICATION FOR REDOMESTICATION BINDER 1 of2

4 Applicant Name: Symetra Life Insurance Company NAIC No FEIN: Unim Certificate of Authority Application (UCAA). Primary Application To the Insurance Commissionerffiirector/Superintendent of the State of: (Check the appropriate states in which you are applying.) Alabama Montana Alaska Nebraska Arizona Nevada Arkansas New Hampshire Calinia New Jersey Colorado New Mexico District of Columbia New York Connecticut North Carolina Delaware North Dakota Florida Ohio Georgia Oklahoma Hawaii. Oregon Idaho. Pennsylvania Illinois Rhode Island Indiana South Carolina Iowa South Dakota Kansas Tennessee Kenrucky Texas Louisiana Utah Maine Vermont Maryland Virginia Massachusetts Washington.. Michigan West Virginia Minnesota Wisconsin Mississippi Wyoming Missouri The undersigned Insurer hereby certifies that _the classes of insurance as indicated on the Lines of Insurance, Form 3, are all lines of business (a) currently authorized transaction,.(b) currently transacted and (c) which the Insurer is applying to transact. Name of Insurer: Symetra Life Insurance Company NAIC # ::o_.._ii._.2::'9'--, Group Code Home Office Address: "' Avenue. Suite 1200 Bellevue. WA Administrative Office Address: 777 I 08"' Avenue. Suite 1200 Bellevue, WA ~ Mailing Address: PO Box Seattle WA Phone:425/ Fax: Are these addresses the same as those shown on your Annual Statement? Yes [][]No c=j If not, indicate why National Association of Irisumnce Commissioners (rev)september 7, 2006 FORM 2P

5 Applicant Name: Symetra Life Insurance Company NAIC No FEIN: Date Incorporated: January Form of Organization: Comoration Billing Address: PO Box Seattle. W A Address: Phone: Fax: Premium Tax Statement Address: PO Box Seattle. W A == Address: Phone: Fax: Producer Licensing Address: PO Box Seattle. WA Address: Phone: Fax: Rate/Form Filing Address: PO Box Seattle WA Address: Phone: Fax: Consumer Affairs Address: PO Box Seattle, WA ;: " Address: Phone: Fax: State or Country of Domicile: Washington State Date Organized. January Date of Last Amendment ofchaner, Bylaws or Subscriber's Agreement: December By-Laws, May Articles of lncomoration: SLIC has no Charters. Date of L.St Financial Examination:.!.1.,2/"'3"1'-'/2,0"'1,0 Date of Last Market Conduct Examination: Forthe period 711/2010 through 6/30/2011- adopted 2/12/12...:., Par Value oflssued.stock: $ ;, Surplus as regards policyholders: $1,935,597,504 as of9/30113 Certificate of Deposit (Home State)$ 4, Ultimate Owner/Holding Company: Symetra Financial Comoration directly owns and controls 100% of the Applicant's issued and outstanding shares. The ultimate controlling person is White Mountains Insurance Group. Ltd.. which. as of September owns and controls approximately 1'7% of the issued and outstanding shares ofsymetra Financial Comoration. Has your company ever been refused admission to this or any other state prior to the date of this application? Yes D No[}[] If Yes, give full explanation in an attached letter. The applicant hereby designates (name natural persons only) Keren Herzberg, to appoint persons and entities to act as and to be licensed as agents in the State of Iowa, and to terminate the said appointments. (I NOTE: This does not apply to those states that do not require appointments The following inmation is required of the individual who is authorized to represent the applicant bee the department. Name David Goldstein Title SVP & General Counsel Mailing Address " Avenue NE Bellevue WA Address: david.goldstein@svmetra.com Phone: 425/ Fax: CLaw Depanment) If the representative is not employed by the applicant, please provide a company contact person in order to facilitate requests detailed financial inmation. NameN~/A~~ Title Mailing Address National Association of Insurance Commissioners (rev)september 7, 2006 FORM lp

6 Applicant Name: Symetra Life Insurance Company NAIC No FEIN: Address: Phone: F~: Please provide a listing of all other applications filed by the applicant, or any of its affiliates, that are pending bee the Department. The applicant's affiliate. Symetra National Life Insurance Company, has filed an expansion application with the Iowa Division of Insurance. Following receipt of approval of this expansion apijiication.-syrrietra National Life Insurance Company intends to file an application to redomesticate from Washington _to Iowa. Applicant Officers' Certification and Attestation One of the officers (listed below) of the Applicant must read the following very carefully: I I hereby certify, under penalty of perjury,.that I have read the application, that I am familiar with its contents, and that all of the infonnation, including the attachments, submitted in this application is true and complete. I am aware that submitting false infonnation or omitting pertinent or material infonnation in connection with this application is grounds license discipline or other administrative action and may subject ine or the Applicant, or both, to civil or criminal penalties. I acknowledge that I am familiar with the insurance laws and regulations of said state, accept the Constitution of such state, in which the Applicant is licensed or to which the Applicant is applying licensure. I acknowledge that I am the Senior Vice President. General Counsel & Secretarv of the Applicant, am authorized to execute and am executing this document on behalf of the Applicant. I hereby certify under penalty of perjury under the laws of the applicable jurisdictions that all of the going is true and correct, executed this at Bellevue, washington. Date Signature of President /) Full Legal Name of President L/ '-"'=A ~AA" Signature of Secretary David Seth. Goldstein Full Legal Name of Secretary Date Signature of Treasurer Full Legal Name of Treasurer Symetra Life Insurance Company Signature of Witness National Association of Insurance Commissioners (rev)septembcr 7, 2006 FORM2P

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8 Applicant Name: Svmetra Life Insurance Company NAIC No FEIN: '"'1,--4-= Unim Certificate of Authority Application (UCAA) Expansion Application Lines of Insurance Please complete the infonnation below each state in which you are currently licensed and seeking authority to do business. Each state has its own terminology the lines of insurance. To assist in completing this fonn and in understanding the tenns used, a matrix is available that correlates each state's tenns to the common tenns used in the NAIC annual statement blanks. The correlation matrix is an Excel spreadsheet and is located on the UCAA web site at httn:// ucaa ms state lines of business matrix.xls ALABAMA Life!Sec ) Disabi~Sec ) Prooertv!Sec ) Miscellaoeous CasuaTtVISec , , , Y Title (Sec ) io!! ALASKA Life! AS l Health (AS ) Disabilitv ) Annuities (AS \ Variable Life las ) Variable AnnuitieS! AS ) Prooertv (AS ) CasualtVfAS lincludinl! clauses: m Vehicle (2) Liability 3 Workers Comoensation aod Emolovers Liability 4 Burglary and Theft 5 Personal Prooertv Floater 6) Glass 7 Boiler and Machinerv 8) Leakaee and Fire Extinguishing Eouinment (9) Credit (failure of debtors to pay obligations to insuredl. (10 Maloractice lril Elevator 1!21 Livestock (13 Entertainments 1141 Miscellaneous Surety!AS ) Marine, Wet Marine & Transoortation (AS ) Mort;,l;e GuarantvrAS ) Title! AS Fraternal Benefit Societv (AS 21.84) io!! ARIZONA Casualty with Workers' Comoensation A.R.S CasuaftV without Workers' Comoensation A.R.S Disability A.R.S io!! 2012 National Association oflnsurance Commissioners Revised 11/26112

9 Applicant Name: Symetra Life Insurance Company NAIC No , FEIN: ARIZONA (continued) Life (Includes Annuities) A.R.S Variable Annuity A.R.S (2) Variable Life A.R.S (15) Marine and Transportation A.R.S Mortgage Guaranty A.R.S Prepaid Legal A.R.S Property A.R.S Surety A.R.S Title A.R.S Vehicle A.R.S Life & Disability Reinsurer A.R.S Health Care Services Organization A.R.S Health, Medical, Dental, Optometric Service Corporations A.R.S Prepaid Dental Plan Organization A.R.S I io~ ARKANSAS Life (ACA ) Accident & Health (ACA ) Property (ACA ) Casualty (ACA ) Surety (ACA ) Workers Compensation (ACA ) Marine (ACA ) Title (ACA ) Mortgage Guaranty (ACA ) ine CALIFORNIA Life(CIC 101) Fire (CIC I 02) Marine (CIC 103) Title (CIC 104) Surety (CIC 1 05) Disability (CIC I 06) Plate Glass (CIC 1 07) Liability (CIC 108) Workers' Compensation (CIC 109) Common Carrier Liability (CIC 110) Boiler and Machinery (CIC Ill) Burglary (CIC 112) Credit (CIC 113) Sprinkler (CIC 114) Team and Vehicle (CIC 115) Automobile (CIC 116) Mortgage (CIC 117) Aircraft (CIC 118) Mortgage Guaranty (CIC 119) Insolvency (119.5) io~ 2012 National Association of Insurance Commissioners 2 Revised 11126/12

10 Applicant Name: Symetra Life Insurance Company NAlC No FEIN: :-:1--::4:: CALIFORNIA ( eontinued) Legal (CIC 119.6) Miscellaneous (CIC 120) Financial Guaranty (CIC 124) Transaet ing COLORADO Life ( (l)(b)) General Life Accident and Health Annuities Credit Variable Contracts Fraternal Benefit Society ( ) General Life Accident and Health Annuities Variable Contracts Title (Title 10, Article 11) Title Property and Casualty (Title 10, Article 3, Sections 102(1)(a), (c) and (d) or (Title 10 Articles 12 or 13) General Property Crop Motor Vehicle General Casualty Accident and Health Fidelity and Surety (excluding bail bond) Bail Bond Workers' Compensation Mortgage Guaranty Credit Professional Malpractice ine CONNECTICUT (C.G.S Title 38a) ing Fire, Extended Coverage and Other Allied Lines Homeowners multiple peril Commercial multiple peril Earthquake Growing crops. Ocean marine Inland marine Accident and health Workers' Compensation Liability other than auto (B.!. and P.O.) Auto liability (B. I. and P.D.) Auto physical damage Aircraft (all perils) Fidelity and Surety 2012 National Association of Insurance Commissioners 3 Revised 11/26/12

11 Applicant Name: Symetra Life Insurance Company NAIC No FEIN: ::-:1-:-47:: CONNECTICUT (C.G.S Title 38a) (continued) Financial Guaranty (mono-line) Glass Burglary and Theft Boiler and Machinery Credit Reinsurance Life Non-Participating Life Participating Variable Life Non-Participating Variable Life Participating Variable Annuities Title Fraternal Benefit Societies Health Care Center Credit Life Credit Accident and Health Mortgage Guaranty (mono-line) Residual Value io~ DELAWARE Life 18 Del. C. Section 9021 Variable Annuities [Del. Reg I] Variable Life [Del. Reg 44] Credit Life [18 Del. C. Section 902] Credit Health [18 Del. C. Section 9031 Health [18 Del. C. Section 9031 Property [18 Del. C. Section 904] Surety [ 18 Del. C. Section 905] Casualty [18 Del. C. Section 906(a)), including subdivisions: (I) Vehicle (2) Liability (3) Workers' Compensation & Employer's Liability (4) Burglary & Theft (5) Personal Property Floater (6) Glass (7 Boiler & Machinery (8 Leakage & Fire Extinguisher Equipment (9 Credit (10 Malpractice (II Elevator (12 Congenital Defects (13 Livestock. (14 Entertainments (15 Miscellaneous Marine & Transportation [18 Del. C. Section 907] Title [ 18 Del. C. Section 908] in National Association of Insurance Commissioners 4 Revised

12 Applicant Name: Svmetra Life Insurance Company NAIC No cc-c-= FEIN: Presently, lines listed above casualty are checked off as individual lines on the certificate of authority application m. 18 Del. C. Section 906(b) - Provision of medical, hospital, surgical and funeral benefits, and of coverage against accidental death or injury, as incidental to and part of other insurance as stated under subdivisions (1) vehicle, (2) liability, (4) burglary & theft, (7) boiler & machinery, (10) malpractice and (11) elevator of subsection (a) shall all purposes be deemed to be the same kind of insurance to which it is so incidental and shall not be subject to provisions of this title applicable to life and health insurance. DISTRICT OF COLUMBIA Health Maintenance Organizations (Sec. 31 -Chapter 34) Life and Health Individual Life Group Life Variable Life (26 DCMR Chapter 27) Individual Accident and Health Group Accident and Health Individual Annuities (Fixed and Variable) (Sec ) Group Annuities (Fixed and Variable) (Sec ) Fire and Casualty (1) Fire (Sec ) (2.1) Allied Lines (Sec ) (2.2 Multiple Peril Crop (2.3) Federal Flood (3) Farmowners Multiple Peril (Sec ) (4) Homeowners Multiple Peril (Sec ) (5.1) Commercial Multiple Peril (non-liability) (Sec ) (5.2) Commercial Multiple Peril (liability) (Sec ). (6) Mortgage Guaranty (8 Ocean Marine (Sec ) (9 Inland Marine (Sec ) 10 Financial Guaranty 11 Medical Malpractice 12 Earthquake (Sec ) 13 GroU]l Accident & Health (Sec ) 14 Credit A&H (Group & Individual) (Sec ) 15.1 Collectively Renewable A&H (Sec ) 15.2 Non-cancellable A&H (Sec ) 15.3 Guaranteed Renewable A&H (Sec ) (15.4) Non-renewable Stated Reasons Only (Sec ) (15.5 Other Accident Only (Sec ) (15.6) All Other A&H (Sec ) 15.7) Federal Employees Health Benefits Program 16 Worker's Compensation (Sec ) 17 Other Liability (Sec ) 18 Products Liability (Sec ) (19.1) Private Passenger Auto No-Fault (personal injury protection) (Sec ) (19.2) Other Private Passenger Auto Liability (Sec ). (19.2 Auto Liability (Sec ) (19.3) Commercial Auto Ne>-Fault (personal injury protection) (Sec ) io!! 2012 NationaJ Association of Insurance Commissioners 5 Revised 11/26/12

13 Applicant Name: Symetra Life Insurance Company NAIC No FEIN: '"'1"'"47:: DISTRICT OF COLUMBIA {continued) (19.4) Other Commercial Auto Liability {Sec ) {21.1) Passenger Auto Physical Damage {Sec ) {21.2) Commercial Auto Physical Damage (Sec ) {22) Aircraft {all perils) (Sec ) (23) Fidelity (Sec ) (24) Suretv (Sec ) {26)Burglary and Theft {Sec ) (27) Boiler and Machinery (Sec ) (28) Credit (Sec , ) Title [Sec {a){7)] ing FLORIDA Property & Casualty Insurers 0010 Fire 0020 Allied Lines 0030 Farmowners Multi Peril 0040 Homeowners Multi Peril 0050 Commercial Multi Peril 0080 Ocean Marine 0090 Inland Marine 0100 Financial Guaranty 0106 Auto Warranties OliO Medical Malpractice 0120 Earthquake 0160 Workers' Compensation 0170 Other Liability 0173 Prepaid Legal 0192 Private Passenger Auto Liability 0194 Commercial Auto Liability 0211 Private Passenger Auto Physical Damage 0212 Commercial Auto Physical Damage 0220 Aircraft 0230 Fidelity 0240 Surety 0245 Bail Bonds 0250 Glass 0260 Burglary and Theft 0270 Boiler and Machinery 0280 Credit 0285 Title {Title Companies Only) 0290 Livestock 0300 Industrial Fire 0310 Mortgage Guaranty 0441 Credit Disability 0450 Accident and Health 0520 Industrial Extended Coverage 0540 Mobile Home Multi Peril 0550 Mobile Home Physical Damage 0570 Crop Hail 0607 Home Warranties in National Association oflnsurance Commissioners 6 Revised 11/26112 FORMJ

14 Applicant Name: Syrnetra Life Insurance Company NAlC No FEIN: "'1--, FLORIDA (continued) 0608 Service Warranties 0610 Other Warranty 0620 Miscellaneous Casualty Property & Casualty Insurers (Reinsurance Only) ROIO Fire R020 Allied Lines R030 Farrnowners Multi Peril R040 Homeowners Multi Peril ROSO Commercial Multi Peril R080 Ocean Marine R090 Inland Marine Rl 00 Financial Guaranty Rl06 Auto Warranties RllO Medical Malpractice Rl20 Earthquake Rl60 Workers' Compensation R 170 Other Liability Rl73 Prepaid Legal Rl92 Private Passenger Auto Liability Rl94 Commercial Auto Liability R211 Private Passenger Auto Physical Damage R2I2 Commercial Auto Physical Damage R220 Aircraft R230 Fidelity R240 Surety R245 Bail Bonds R250 Glass R260 Burglary and Theft R270 Boiler and Machinery R280 Credit R285 Title (Title Companies Only) R290 Livestock R300 Industrial Fire R31 0 Mortgage Guaranty R441 Credit Disability R450 Accident and Health R520 Industrial Extended Coverage R540 Mobile Home Multi Peril R550 Mobile Home Physical Damage R570 Crop Hail R607 Home Warranties R608 Service Warranties R610 Other Warranty R620 Miscellaneous Casualty Life, Accident and Health Insurers 0400 Ordinary Life. Endowment Term Life Industrial Life Individual Annuities Universal Life 0405 Individual Variable Annuities ing National Association of Insurance Commissioners 7 Revised 11/26/12 FORMJ

15 Applicant Name: Symetra Life Insurance Company NAIC No FEIN: :-:1-:-4 7:: FLORIDA (continued) ing Group Variable Annuities 0410 Group Life and Annuities 0420 Variable Life 0425 Fraternal Life 0430 Fraternal Health 0440 Credit Life 0441 Credit Disability 0450 Accident and Health R400 Reinsurance - Ordinary Life and Annuity R405 Reinsurance- Individual/Group Variable Annuities R410 Reinsurance- Group Life and Annuity. R420 Reinsurance- Variable Life R440 Reinsurance ~ Credit Life R441 Reinsurance - Credit Disability R450 Reinsurance - Accident and Health For purposes of applicant's plan of operations, these lines should be listed as "all other lines". If any are combined with other lines on the pro ma (i.e. mobile home combined with homeowners), the plan of operations should specify that this was done. GEORGIA Life, accident, and sickness, including subdivisions: Variable Annuities Variable Life Property, marine, and transportation Casualty, subdivisions: Workers' Compensation (including) Workers' Compensation (excluding) Surety Title ine HAWAII Life Insurance (Section 431: 1-204, HRS) Disability Insurance (Section 431: 1-205, HRS) Property Insurance (Section 431: 1-206, HRS) Marine and Transportation Insurance (Section 431: 1-207, HRS) Vehicle Insurance (Section 431: 1-208, HRS) General Casualty Insurance (Section 431:1-209, HRS) Surety Insurance (Section 431: 1-210, HRS) Ocean Marine (Section 431: 1-211, HRS) Title Insurance (Section 431: 20, HRS) ine IDAHO Life Disability (Including/Excluding Managed Care) Variable Annuities/Contracts- ( 4 I -1936) Property ine 2012 National Association oflnsurance CommissionerS 8 Revised 11/26/12

16 Applicant Name: Symetra Life Insurance Company NAIC No FEIN: 9I-0742ocl:-:4:: ~ IDAHO (continued) Marine and Transportation Casualty -Including Workers' Compensation Casualty- Excluding Workers' Compensation Surety (Including Fidelity) Mono line only: Title Mortgage Guaranty in2 ILLINOIS Class 1 Life, Accident and Health* (a) Life (b) Accident and Health (c) Legal Expense Insurance Class 2 Casualty, Fidelity and Surety* (a) Accident and Health (b) Vehicle (c) Liability (d) Workers' Compensation (e) Burglary and Forgery (f) Glass (g) Fidelity and Surety (b) Miscellaneous (i) Other Casualty Risks G) Contingent Losses (k) Livestock and Domestic Animals (I) Legal Expense Insurance Class 3 Fire and Marine, etc. (a) Fire (b) Elements (c) War, Riot and Explosion (d) Marine and Transportation (e) Vehicle (f) Property Damage, Sprinkler Leakage and Crop (g) Other Fire and Marine Risks (b) Contingent Losses (i) Legal Expense Insurance in2 See 215/IL5/4 additional description INDIANA Class I (Life) (a Life and Annuities (b Accident & Health (c Variable Life and Annuities (Segregated Amounts) Class II (Casualty) (a) Accident and Health -Disability (b) Workers' Compensation (c) Burglary, Theft (d) Glass (e) Broiler and Machinery ing 2012 National Association of Insurance Commissioners 9 Revised 11/26/12

17 Applicant Name: Svmetra Life Insurance Company NAIC No FEIN: ::-:lcc4:: INDIANA (continued) (f) Automobile (g) Sprinkler (h) Liability i Credit ~il Title :I< Fidelity & Surety w/bailbonds (kt) Fidelity & Surety w/o Bailbonds (I) Miscellaneous (m) Legal Expenses Classiii(Property) (a Fire, Windstorm, Hail, Loot, Riot (b) Crops (c) Sprinkler (d) Marine inl! IOWA Property/Casualty Lines (515.48) Fire Extended Coverage Other Allied Lines Homeowners Multiple Peril Commercial Multiple Peril Earthquake Growing Crops Ocean Marine Inland Marine Accident and Health. Workers' Compensation Other Liability Auto Liability Auto Physical Damage Aircraft Fidelity and Surety Glass Burglary and Theft Boiler and Machinery Reinsurance Only (monoline) Financial Guaranty (monoline) Life (508, 509, 51 I)* Life with accident and health (508, 509, 51 I and 515)* Reciprocal (520) Mortgage Guaranty (515C) Fraternal (5 12B) io!! *Life includes credit life, variable life, annuities, and variable annuities. KANSAS Life Accident and Health Stand-alone Prescription Drug Provider ing 2012 National Association of Insurance Commissioners 10 Revised 11/26/12

18 Applicant Name: Svmetra Life Insurance Company NAlC No FEIN: ;:-:1:-:4:; KANSAS (continued) Fire Insurance Fire Windstorm & Hail Extended Coverage Add'!. Perils on Growing Crops Hail on Growing Crops Optional Perils Sprinkler Leakage Business Interruption Earthquake Water Damage Aircraft Hull Ocean Marine Inland Marine Rain Automobile Physical Damage Flood Homeowners Policies Casualty Insurance Accident and Health Automobile Liability General Liability Workers' Compensation Fidelity, Surety & Forgety Bonds Glass Burglarv, Theft & Robbery Boiler & Machinery Credit Title Malpractice Liability Livestock Mortality Aircraft Liability Cargo Liability ' Mortgage Guaranty Insurance ing KENTUCKY Life And Health Companies Life (Includes variable & credit)krs Annuity (Includes variable)krs Health (Includes credit) KRS Property And Casualty Companies Health (Includes credit) KRS Property KRS Suretv KRS Casualty KRS All Lines KRS (I)( a) thru (l)(q) Or, Casualtv Limited to: Vehicle Insurance KRS ?0(l)(a) Liability Insurance KRS ?0(l)(b) Workers' Compensation and Employers Liability KRS (1 )(c) ing 2012 National Association of Insurance Commissioners II Revised 11/26112

19 Applicant Name: Svmetra Life Insurance Company NAIC No FEIN: '""'1...,.47= KENTUCKY (continued) Burglary and Theft KRS (1)(d) Personal Property Floater KRS (1)(e) Glass KRS (1 )(f) Boiler and Machinery KRS (1)(g) Leakage and Fire Extinguishing Equipment KRS (l)(h) Credit KRS (1)( i) Malpractice KRS (1)(j) Elevator KRS (1)(k) Congenital Defects KRS (1 )(!) Livestock KRS (1 )(m) Entertainments KRS (1 )(n) Failure of Certain Institutions to Record Documents KRS (o) Automobile Guaranty KRS (1)(p) Miscellaneous KRS (1 )(q) Marine and Transportation KRS Mortgage Guaranty KRS Title KRS All Others Companies: Fraternal Benefit Society KRS Life Health Lloyd's KRS I 0 Non-profit Health Service Corporation KRS Reciprocal KRS inl! LOUISIANA Life Annuities Health and Accident Vehicle Liability Workers' Compensation Fire and Allied Lines Fidelity Surety Credit Life, Health and Accident Credit Property and Casualty Marine and Transportation Miscellaneous Steam Boiler and Sprinkler Leakage Title Vehicle Burglary and Forgery Crop HomeOwners io!! 2012 NationaJ Association of Insurance Commissioners 12 Revised 11/26/12

20 Applicant Name: Symetra Life Insurance Company MAINE Life and Health Life, including credit life Health, including credit health Variable Life Variable Annuity Property & Casualty Fire Allied Lines Farmowners Multiple Peril Homeowners Multiple Peril Commercial Multiple Peril Mortgage Guaranty Ocean Marine Inland Marine Financial Guaranty Worker's Compensation Medical Professional Liability Earthquake Other Liability Product Liability Auto Liability Auto Physical Damage Aircraft (all perils) Fidelity Surety Glass Burglary and Theft Boiler and Machinery Credit Federal Flood Insurance Title MARYLAND Insurance Article of the Annotated Code of Maryland Variable Annuities- Section 1-lOl(d)(e), Casualty (not including Vehicle Liability, Mortgage Guaranty & Worker's Compensation)- Section 1-IOl(i) Dental Plan Organization- Section Fraternal Mortgage Guaranty- Sections ( oo) Health - Sections I (p) Life, including Annuities and Health (except Variable Life & Variable Annuities) Sections 1-lOl(d), 1-!0l(p), 1-IOI(x) Marine, Wet Marine & Transportation- Sections 1-1 Ol(z), 1-IOI(ss) Non-Profit Health Service Plan- Section Property and Marine (excluding Wet Marine and Transportation)- Section 1-10 I (gg), (1-1 0 I (z) Variable Life- Sections , Surety- Section 1-IOI(oo) NAIC No FEIN: '""'1--,-47= io~.. io!! 2012 National Association of Insurance Commissioners 13 Revised 11/26/12 FORMJ

21 Applicant Name: Symetra Life Insurance Company NAIC No FEIN: ::-:1-:-4 7:: MARYLAND (continued) Title- Section 1-10 I(qq) Vehicle Liability- Section 1-IOI(i) Workers' Compensation- Section 1-101(:) Health-General Article of the Annotated Code of Maryland Health Maintenance Organizations- Sections , , Provider-Sponsored Organizations- Section 19-7 A ing MASSACHUSETTS I {M.G.L ) (I) Fire. (2A Ocean Marine (2B) Inland Marine Only (4) Fidelity and Surety (SA) Boiler, Fly Wheel, Machinery, Explosion (5B) Boiler (no inspector), Fly Wheel, Machinery, Explosion (6A) Accident - All Kinds (6B) Health - All Kinds j6c) Group Accident and Health Only (6D) Non-Cancelable Accident and Health Only 6E) Workers' Compensation 6F) Liability Other than Auto 6G) Auto Liability (7) Glass (8 Water Damage and Sprinkler Leakage (9) Elevator Property Damage and Collision (10) Credit (I I) Title (Title Companies Only) (12) Burglary, Robbery, Theft, Forgery, Larceny (13 Livestock (15) Reinsurance (16A) Life - All Kinds (16B Group Life Only 16C Variable Annuity Authorization (16D Annuities Only 16E Variable Life Authorization (I 7) Repair - Replacement (19 Legal Services (20) Credit Involuntary Unemployment (51) Stock Companies Extension of Coverage- M.G.L I(g) (54) Mutual Companies (specified in Section 47) - M.G.L (g) (54B) Reinsurance except Life- M.G.L B (54 BY) Nuclear Energy- M.G.L B (54BZ) Special Hazards- Radioactive Contamination - M.G.L B (54C) Comprehensive Motor Vehicle and Aircraft- M.G.L C (54 D) Personal Property Floater- M.G.L D ing 2012 National Association of Insurance Commissioners 14 1\evised 11126/12 FORMJ

22 Applicant Name: Symetra Life Insurance Company NAIC No FEIN: MASSACHUSETTS (continued) (54 E) Dwellings- M.G.L E (54 F) Commercial Property (Multiple Peril)- M.G.L F (54G) Reinsurance- Life Companies Only- M.G.L G io!! MICHIGAN Life and Annuity- Other than Variable Contracts (MCL ) Separate Account- Variable Annuities (MCL ) Separate Account- Variable Life (MCL ) Separate Accounts - Modified Guaranteed Annuities (MCL ). Disability (MCL ) Property (MCL ) Ocean Marine (MCL ) Inland Marine (MCL ) Automobile Insurance- Limited (MCL ) Legal Expense (MCL ) Steam Boiler, Flywheel and Machinery (MCL a) Liability (MCL b) Automobile, including Section 625, disability coverage supplemental to automobile insurance {MCL b) Workers Compensation (MCL b) Plate Glass (MCL c) Sprinkler and Water Damage (MCL d) Credit (MCL e) Burglary and Theft {MCL !) Livestock (MCL g) Malpractice (MCL h) Miscellaneous (MCL i) Surety and Fidelity (MCL ) Limited Liability (MCL 500 Chapter 65) Title (MCL 500 Chapter 73) Fraternal (MCL 500 Chapter 81a) io!! MINNESOTA (MS 60A.06, Subd.l) Fire (I) Inland Marine (2a) Ocean Marine (2a) Personal Property Floater (2b). Boiler and Machinery (3) Life (4) Variable Contract Authority (4) Accident and Health (Sa) Worker's Compensation (Sb) Fidelity (6) Surety 6) Title (7) Glass (8) io!! 2012 National Association of Insurance Commissioners 15 Revised 11126/12

23 Applicant Name: Symetra Life Insurance Company NAIC No FEIN: :-:1--:4::: MINNESOTA (MS 60A.06, Subd.1) (continued) Burglary & Theft (9a) Security and Drafts (9b) Personal Property Floater - Casualty (9c) Water (9d) Livestock (I 0) Credit (II) Automobile (12) General Liability (13) Elevator (14) Lega1Expense(l5) in2 MISSISSIPPI (MCA Classifications of Insurance Companies) Class 1. Fire and Casualty (a) Fire and Allied Lines (b) Industrial Fire (c) Casualty/Liability (d) Fidelity (e) Surety (f) Workers' Compensation (g) Boiler and Machinery (b) Plate Glass (i) Aircraft (i) Inland Marine (k) Ocean Marine (I) Automobile Physical Damage/ Automobile Liability (m) Homeowners/Farmowners (n) Guaranty (o) Mortgage Guaranty (p) Title (q) Trip Accident and Baggage (r) Legal (s) Credit Property Class 2. Life (a) Life (b) Accident and Health (c) Credit Life, Credit Accident and Health (d) Industrial Life, Industrial Accident and Health (e) Variable Contracts (f) Life (Burial) Class 3. Fraternal (a) Fraternal (b) Larger Fraternal Class 4. Burial MCA Health Maintenance Organization in2 MISSOURI A - Life and Health (RSMo 3 76) AI- Life, Annuities and Endowments ( ) ing 2012 National Association of Insurance Commissioners 16 Revised 11/26/12

24 Applicant Name: Symetra Life Insurance Company NAIC No FEIN: :-:1:-:4-:: MISSOURI (continued) A2- Accident and Health ( ) H- Title (RSMo 381) 81- Property ( (1)) 82- Liability ( (2)) Workers' Compensation 83- Fidelity and Surety ( (3)) 84- Accident and Health ( (4)) 85- Miscellaneous ( (5)) io~ MONTANA Life (including variable contract authority) ; Part 6, MCA Life (excluding variable contract authority) , MCA Disability 33-l-207, MCA Property , MCA Casualty (including Workers' Comp) 33-l-206, MCA Casualty (excluding Workers' Comp) & , MCA Surety , MCA Marine & , MCA Title , MCA ing NEBRASKA Life (I) Variable Life (2) Variable Annuities (3) Sickness & Accident ( 4) Property (5) Credit Property ( 6) Glass (7) Burglary & Theft (8) Boiler & Machinery (9) Liability (10) Workers Compensation &Employers Liability (II) Vehicle (12) Fidelity (13) Surety (14) Title (15) Credit (16) Mortgage Guaranty (17) Marine (18) Financial Guaranty (19) Miscellaneous (20) ing NEVADA Life (681A.040) Health (68!A.030) Property (681A.060) Casualty (681A.020) (Including Worker's Comp) ing 2012 National Association of Insurance Commissioners 17 Revised 11126/12

25 Applicant Name: Symetra Life Insurance Company NAIC No , FEIN: 9I NEVADA (continued) Casualty (681A.020) (Excluding Worker's Comp) Surety (681A.070) Marine and Transportation (681A.050) Title (681A.080) Surplus Lines (685A) Risk Retention Group (695E) Funeral/CemetaJy Sellers (689) Premium Finance Company (686A) Motor Clubs (696A) Health Maintenance Organization (695C) Prepaid Ltd. Health Service Organization (695F) Variable (688A) Home Warranty (680B.1 00) ing NEW HAMPSHIRE Fire and Allied Lines(RSA 401.1, I) Marine Coverages(RSA 401.1, II) Life and Annuities(RSA 401.1, III) Variable Annuities require a separate License (RSA , lll) Accident and/or Health Coverages (401.1, IV) Liability Coverages, including workers' compensation (RSA 401.1, V) Casualty Coverages ( RSA 401.1, VI) Fidelity, Surety, Credit Insurance, Mortgage Guaranty, Bonds, and Financial Guaranty (RSA 401.1, VII) Other casualty risks. Refer to the NAIC Unim P&C Product Coding Matrix filing code 17. Select each Sub-Type to which this license is being requested. (RSA 401.1, VIII) Title (RSA 416-A) Fraternal (RSA 418:16) ing.. NEW JERSEY (1) Fire (N.J.S.A. 17:17-1a) (2) Earthquake (N.J.S.A. 17: I 7-la) (3) Growing Crops (N.J.S.A. 17:17-la) (4) OceanMarine(N.J.S.A. I7:17-1b) (5) Inland Marine (N.J.S.A. I7:17-1b) (6) Workers' Compensation and Employers Liability (N.J.S.A. 17:17-1e) (7) AutomobileLiability(BI)(N.J.S.A.17:17-1e) (8) AutomobileLiability(PD)(N.J.S.A.17:17-le) (9) Automobile Physical Damage (N.J.S.A. 17:17-le) (10) AircraftPhysicalDarnage(N.J.S.A.l7:17-lb) (II) Other Liability (N.J.S.A. 17:17-le) (12) Boiler & Machinery (N.J.S.A. 17:17-lf) (13) Fidelity & Surety (N.J.S.A. 17:17-1g) (14) Credit(N.J.S.A. 17:17-li) (15) Burglary& Theft (N.J.S.A. 17:17-lj) ine 2012 Nationa1 Association oflnsurance Commissioners 18 Revised 11/26/12

26 Applicant Name: Symetra Life Insurance Company NAIC No FEIN: :-:1-:-4:: ~ NEW JERSEY (continued) (16) Glass(N.J.S.A. 17:17-lk) (17) Sprinkler Leakage (N.J.S.A. 17:17-ll) (18) Livestock (N.J.S.A. 17:17-lm) (19) Smoke & Smudge (N.J.S.A. 17:17-ln) (20) Physical Loss to Buildings (N.J.S.A. 17:17-lo) (21) Radioactive Contaminaiion (N.J.S.A. 17: 17-lo) (22) Mechanical Breakdown/Power Failure (N.J.S.A. 17:17-lo) (23) Other (must be pre-approved by the Commissioner) (N.J.S.A. 17: 17-lo) (26) Accident and Health (Property/Casualty Companies) (N.J.S.A. 17B:l7-4) (27) Municipal Bond (N.J.A.C. II :7) (28) Life (N.J.S.A. 17B: 17-3) (29) Accident and Health (Life/Health Companies) (N.J.S.A. 17B:I7-4) (30) Annuities (N.J.S.A. 17B:I7-5) (31) Variable Contracts (N.J.S.A. 17B:28-I et seq.) (33) Title (N.J.S.A. 17:46B-7) (34) Fraternal Benefit Society (N.J.S.A. 17:44B) (35) Residential Mortgage Guaranty (N.J.S.A. 46A-3) (36) Commercial Mortgage Guaranty (N.J.S.A. 46A-3) ine x NEW MEICO Life (NMSA Section 59A-7-2) Health (NMSA Section 59A-7-3) Property (NMSA Section 59A-7-4) Marine and Transportation (NMSA Section 59A-7-5) Casualty (NMSA Section 59A-7-6)_ Vehicle (NMSA Section 59A-7-7) Surety (NMSA Section 59A-7-8) Title (NMSA Section 59A-7-9) ing NEW YORK (Notes 1 and 2) (Section 1113(a) of the N.Y. Ins. Law) (I) Life (2) Annuities (3) (i) &(ii)- A&H (4) Fire (5) Miscellaneous Property (6) Water Damage (7) Burglary & Theft (8) Glass (9 Boiler and Machinery (10 Elevator (II Animal (12) Collision (13) Personal Injury Liability (14) Property damage liability (I 5) Workers' Compensation and employers' liability (16) Fidelity and surety 2012 NationaJ Association of Insurance Commissioners 19 ine Revised 11/26/12

27 Applicant Name: Svmetra Life Insurance Company NAIC No FEIN: '""'1..,.47= NEW YORK (continued) (Notes 1 and 2) ing (17) Credit (19) Motor Vehicle and aircraft physical damage (20) Marine and Inland marine (21) Marine Protection and indemnity (22) Residual value (24) Credit Unemployment (26 Gap (27 Prize Indemnification (28 Service Contract reimbursement (29) Legal Services (30) Involuntary unemployment (31) Salary protection Monolioe only: Title- Section 1113(a)(l8) & Article 64 of the N.Y. Ins. Law Mortgage Guaranty- Section 1113(a)(23) & Article 65 of the N.Y. Ins. Law Financial Guaranty- Section 1113(a)(25) & Article 69 of the N.Y. Ins. Law Note 1: A company may only apply the lines of insurance which it is authorized in its state of domicile. Note 2: The company must have transacted business a minimum of three (3) years prior to seeking admission. If the company was recently acquired, at least three (3) years of operating experience under the new management is required. An affiliated insurer admitted in New York and operating under the same ownership/management team at least three (3) years may satisfy this requirement. If the aementioned situation applies, a written request approval of a waiver must be submitted with the application. NORTH CAROLINA Life (NCGS ) Life, including industrial & credit life Annuities Variable annuities Variable life Accident and health - Cancelable Accident and health - Non-cancelable Accident and health- Credit Fire (NCGS ) Fire Miscellaneous property - Extended coverage Miscellaneous property - Growing crops Water damage - Commercial Water damage- Residence Burglary and theft Glass Animal Collision - Automobile Collision Other Motor vehicle and aircraft- Property damage Motor vehicle and aircraft- Fire Motor vehicle and aircraft- Theft Motor vehicle and aircraft- Comprehensive Motor vehicle and aircraft- Collision ing 2012 National Association oflnsurance Commissioners 20 Revised 11126/12

28 Applicant Name: Symetra Life Insurance Company NAIC No FEIN: ::1:-::4:: NORTH CAROLlNA (continued) Marine- Inland Marine- Ocean Marine protection and indemnity Other Casualty (NCGS ) Accident and health- Cancelable Accident and health- Non Cancelable Accident and health -Credit Water damage- Commercial Water damage - Residence Burglary and theft Glass Boiler and machinery Elevator Animal Collision- Automobile Collision- Other Personal injury liability -Automobile Personal injury liability- Other Property damage liabili_~- Automobile Property damage liability - Other Workers' compensation and Employer's liability Fidelity and surety Credit Title Motor vehicle and aircraft- Property damage Motor vehicle and aircraft- Fire Motor vehicle and aircraft- Theft Motor vehicle and aircraft- Comprehensive Motor vehicle and aircraft- Collision Marine protection and indemnity Aircraft Voluntary Settlement Hole-in-One Other Mortgage Guaranty. ing NORTH DAKOTA Life & Annuity Accident & Health Property Casualty Variable Life and Annuity in2 omo Life Companies: Life, Accident, Health, Disability, and/or annuities (O.R.C ) Property & Casualty (O.R.C l(A) (1) Fire (2) Allied Lines (3) Farmowners Multiple Peril ine: 2012 National Association of Insurance Conunissioners 21 Revised

29 Applicant Name: Symetra Life Insurance Company NAIC No FEIN: "'1--,.4 7 I OHIO (continued) (4) Homeowners Multiple Peril (5) Commercial Multiple Peril (6) Ocean Marine (7) Inland Marine (8) Guaranty (9) Medical Malpractice ( l 0) Earthquake {ll) Group A&H (12) Credit A&H (Group and Individual) (13a) Collectively Renewable A&H (13b) Noncancellable A&H (l3c) Guaranteed Renewable A&H (!3d) Nonrenewable Stated Reasons Only (l3e) Other Accident Only (13f) All Other A&H (14) Workers' Compensation (to the extent permitted by law) (15) Other Liability (16a) Private Passenger Auto No-Fault (personal injury protection to the extent permitted by law) (l6b) Other Private Passenger Auto Liability (l6c) Commercial Auto No-Fault (personal injury protection to the extent permitted by law) (16d) Other Commercial Auto Liability 17a) Private Passenger Auto Physical Damage 17b) Commercial Auto Physical Damage 18) Aircraft (all perils) 19 Fidelity 20 Surety 21 Glass 22) Burglary and Theft 23) Boiler and Machinery 24) Credit (25) Reinsurance Only (26) Other (list) Title Insurance (O.R.C. 3953) ine OKLAHOMA Life (O.S ) Surety (including bail) (OAC 365: ) Surety (excluding bail) (O.S ) Title (O.S ) Marine (O.S ) Accident & Health (O.S ) Property (O.S ) Vehicle (O.S ) Casualty (vehicle only) (O.S ) Casualty (including vehicle)(o.s ) Workers' Compensation (O.S , 612.2) Variable Life (O.S , 6062) ing 2012 National Association of Insurance Commissioners 22 Revised 11126/12

30 Applicant Name: Svmetra Life Insurance Company NAIC No ,.,-= FEIN: , OKLAHOMA (continued) Variable Annuitv (O.S , 6062, OAC 365: ) Reinsurance70.S ) Health Maintenance Organizations (0.S ) ine OREGON Life!ORS l Health (ORS ) Health Care Service Contractoi70RS ) Health Care Service Contractor (Complementary Health Services)!ORS Prooertv (ORS ) CasualtY, excluding Worker's Como (QRS ) Casua!tv, includiiloworker's Comp (ORS \ Marine & Transoortation(ORS ) SuretVIORS ) Home Protection Conlv) (ORS ) Mortgage (on!v) (ORS ) Title (onm(ors 731.!90) ine, PENNSYLVANIA (Notes I and 2) Life and Annuities (40 P.S. & 382(a)(l)) Seoarate Account- Variable Life (40 P.S. & 382 (a)(])) Seoarate Account- Variable Annuities (40 P.S. 382 (a)(!)) Accident and Health (40 P.S. 382(a)(2)) Fire and Allied Lines 140 P.S. 3821bll!)) Inland Marine & Auto Pbvsical (40 P.S. 382(b)(2)) Ocean Marine740 P.S:S 38:2ib)(3)l Fidelitv and SureiVi'40 P.S. 382(c)(l)) Accident and Health (40 P.S. 382(c)(2)) GlassC40 P.S. 382Tc)(J)) Other Liabilit040 P.S. 382 (c)(4)) Steam Boiler & Machinery (40 P.S. 382 (c)(5)) BtiffilaTV-Theft( 40 P. S.S 3 82 Tc\16)) Credit 40 P.S. 382 (c)(7)) Water 40 P.S. 382 (c){8i\ Elevatol740 P.S. 382 (cll9ll Livestock (40 P.S. 382 (c)(]0)) Auto Liability 40 P.S. ~ 3821C){JJ )) Mine & Machinffil40 P.S. 382 (c)(l2)) Personal Prooertv Floater (40 P.S. 382 (c)(l3)) Workers' Cottmensation (40 P.S:S 3821C){J4l\CNote 3\ Other!40 P.s:S 38Uell Title (40 P.S ) ing Note I: A company may only apply the lines of insurance which it is authorized in its state of domicile. Note 2: The company must have transacted business a minimum of one (!)year prior to seeking admission. If the company was recently acquired, at least one (!) year of operating experience under the new management is required. An affiliated insurer admitted in Pennsylvania and operating under the same ownership/management team at least one year may satisfy this requirement. If the aementioned situation applies, a written request approval of a waiver must be submitted with the application National Association of Insurance Commissioners 23 Revised 11126/12

31 Applicant Name: Symetra Life Insurance Company NAlC No FEIN: ::-:l-cc47:: '-- Note 3: The Department of Labor and Industry requires all insurers that are applying to write workers' compensation to complete and file an Initial Report of Accident and Illness Prevention Services. The Insurance Department will not issue a Certificate of Authority to a eign insurer to write workers' compensation insurance until the Department of Labor and Industry has indicated the company has made the necessary filing as required by the Workers' Compensation Act. The necessary m with instructions can be obtained at: RHODE ISLAND ine Life and Health Companies: Life (Note I) Accident and Health (Note 1) Annuities (Note 1) Variable Life (Note 1) Variable Annuity (Note 1) Variable Contracts (Notes 1 and 2) Property and Casualty Companies: (Note 3) Fire Allied Lines Multi-Peril Crop Federal Flood Farmowners Multi-Peril - Homeowners Multi-Peril Commercial Multi-Peril Ocean Marine Inland Marine Medical Malpractice/Medical Liability Earthquake Accident & Health Worker's Compensation Other Liability Products Liability Automobile (Full Coverage) Aircraft (All Perils) Fidelity Surety Glass Burglary and Theft Boiler and Machinery Credit Warranty Financial Guaranty or Mortgage Guaranty A company will be granted authority a line of business in Rhode Island only on the condition that the company already has authority to sell that line in its state of domicile. Note I: Includes individual and group, and credit and non-credit. Note 2: Variable Contracts includes Variable Life and Variable Annuity. Note 3: Or alternatively: all lines except Life, Annuities, Title, Mortgage Guaranty and Financial Guaranty. SOUTH CAROLINA ing Life and Annuities (SC ) Accident and Health (SC ) Property (SC ) Casualty (SC ) 2012 NationaJ Association of Insurance Commissioners 24 Revised 11126/12

32 Applicant Name: Symetra Life Insurance Company NAIC No FEIN: '""'1--,4-= I SOUTH CAROLINA (continued) io!! Surety (SC 38-S-30) Marine (SC ) Title (SC ) SOUTH DAKOTA ing (I) Life (2) Health (3) Fire & Allied Lines (4) Inland & Ocean Marine (5) Workmen's Compensation (6 Bodily Injury Liability (No Auto) (7) Property Damage (No Auto) (8) Auto Bodily Injury (9 Auto Property Damage (10) Auto Physical Damage (II) Fidelity & Surety (12) Glass (13 Burglary (14 Boiler & Machinery (IS Aircraft (16) Credit (includes Credit Life; Credit Health; Credit Mortgage Guaranty and GAP (Guaranteed Auto Protection)) (17) Crop- Hail (18) Livestock (19) Title (20) Variable Annuities (21) Variahle Life (22) Reinsurance Only (Not Companies w/direct authority) (23-A) Travel, Accident & Baggage 23-B) Prepaid Legal 23-C) Bail Bonds 26) Commercial (27) Personal TENNESSEE ing Life {TCA ), (a) Accident and Health (TCA ), (a) Credit (TCA ), (a) Variable Contracts {TCA ), (a) Property (TCA ), (a), (b) Vehicle (TCA ), (a), (c) Casualty (TCA ) (a), (d) Surety (TCA ) (a), (e) Title (TCA ) (a) (a) Company may only write lines in Tennessee that they are authorized to write in their domiciliary state. (b) Includes Fire and Extended Coverage, Other Allied Lines, Homeowners Multiple Peril, Commercial Multiple Peril, Earthquake, Growing Crops, Water Damage- Sprinkler Leakage, Ocean Marine and Inland Marine. (c) Automobile Bodily Injury, Automobile Property Damage and Automobile Physical Damage. (The Vehicle class is to be used when the company requests Vehicle only and no other Casualty line 2012 National Association of Insurance Commissioners 25 Revised 11/26/12

33 Applicant Name: Symetra Life Insurance Company NAIC No FEIN: ::-:I:-:4-:: (d) All lines listed under (c) above in addition to Disability, General Liability, Workers' Compensation, Burglary and Theft, Personal Property Floater, Glass, Boiler, Water Damage, Credit, Elevator, Livestock, Collision, Malpractice, Miscellaneous. (e) Credit, Accident and Health, Fidelity, Permance Contracts and Bonds, Indemnification Insurance and Mortgage Guaranty. TEAS ine; Fire Allied Coverages (a) Hail, growing crops only Rain Inland Marine (b) Ocean Marine Aircraft Liability Auto Physical Damage Accident Health Workers' Comp & Emp. Liability Employer's Liability Automobile Liability (c) Automobile Physical Damage (d) Liability other than Automobile (e) Fidelity and Surety Glass Burglarv and Theft Forgery Boiler and Machinery Credit(D Livestock (g) Prepaid Legal Services (h) Title (i) Mortgage Guaranty Type I Mortgage Guaranty Type II Life Variable Life Variable Annuity When one of the above coverages includes more than one kind or sub-line of insurance, the selection of that coverage authorizes the company to write one or more of the specified kinds of insurance included in that coverage. (a) Includes, but not limited to, Extended Coverage, Windstorm, Lightning, Hurricane, Hail (except growing crops), Explosion, Riot, Civil Commotion, Smoke, Aircraft, Land Vehicles, Physical Loss Form, Additional Extended Coverage, Vandalism, Malicious Mise (b) Includes Personal Property Floater. (c) Includes Bodily Injury, Medical Payments, Property Damage, and other Automobile Liability. If applicant is planning to write commercial automobile liability, a loss control plan must be submitted. (d) Includes Fire, Theft, Collision, Comprehensive and other Automobile Physical Damage. (e) Includes Bodily Injury, Medical Payments and Property Damage with regards to Comprehensive Personal Liability, Owners, Landlords and Tenants, Manufacrurers and Contractors, Product, Contractual, Elevator (including Elevator Collision), Employers' Liability, Professional Liability Physicians, Podiatrists, Certified Anesthetists, and Hospitals, and other Liability other than Automobile. If applicant is planning to write professional liability insurance hospitals, professional liability insureds other than hospitals, general liability and I or medical liability insureds other than hospitals, a loss control plan must be submitted. (f) Includes Credit Involuntary Unemployment; excludes Mortgage Guaranty. (g) Mortality National Association of Insurance Conunissioners 26 Revised 11/26/12

34 Applicant Name: Svmetra Life Insurance Company NAIC No FEIN: ::1:-:47= (h) Prepaid Legal Services business also has separate policy fonns filing requirements. (i) May be written only by Title insurance cnmpanies except tbnse companies transacting title insurance prior to October I, 1967.Inclndes Attorney's Title insurance companies as authorized by Texas Insurance Code, Article L Life, Health, and accident and annuities- Chapter 3 of the Texas Administrative Code a. Life, Health, and accident and annuities Chapter 3 of the Texas Administrative Code b. Mutual Life- Chapter II of the Texas Insurance Code 2. Property and Casualty Insurance Companies- Chapter 5 of the Texas Administrative Code a. Fire and Marine Companies- Chapter 6 of the Texas Insurance Code b. Surety and Trust Companies- Chapter 7 of the Texas Insurance Code c. General Casualty Companies- Cbapter 8 of the Texas Insurance Code UTAH C~pplying T Life Insurance, including variable products, (Utah Code Ann. 31A-I-301 {98)(a)) Accident & Health (Utah Code Ann. & 31A-l-301(1)) ~Code Ann. 31A-1-30! (134)) Surety Insurance (l ode Ann. & JIA (155)) Bail Bond Surety (Utah Code Ann. 31A-I-301{12)\ Vehicle Liability Insurance (Utah Code Ann. 31A )) Liability Insurance (Utah Code Ann. 31A-1-301(96)) Marine and Transport (Utah Code Ann. 31A-l-30 1(80) & (116)) Workers Compensation Insurance (Utah Code Ann. 31A I 301(!66)) Title Insurance (Utah Code Ann. & 31A )) Professional Liability, excluding medical malpractice (Utah Code Ann. 31A-l-301(133) Professional Liability, including medical malpractice (Utah Code Ann. 31A-I-301(106)) Motor Club (Utah Code Ann. 31A-1-301{112) Limited Health Plan (Utah Cnde Ann. 31A-8-IOI (6)) Nonprofit Health Service Corporation (Utah Code Ann. 31A ) Credit Guarantee (Utah Code Ann. 31A-l-301(35)) Legal Expense (Utah Code Ann. JIA-1-301(95)) Health Maintenance Organization (Utah Code Ann. 31A 8-101(5)) VERMONT Life (Section 330l(a)(l)) Variable Annuity (Section 3857) Variable Life (Section 3857) Health (Section 3301(a)(2)) Casualty (Section 3301(a)(3)) Marine and Transportation (Section 3301(a)(4)) Marine Protection and Indemnity (Section 330l(a)(5)) Wet Marine and Transportation (Section 3301(a)(6)) Property (Section 3301(a)(7)) Surety {Section 3301(a)(8)) Title (Section 3301(a)(9)) Multiple Line (Section 330!(a)(!O)) 2012 National Association of Insurance Commissioners 27 Revised 11126/12 FORMJ