Leeway Clause Form
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1Company Name
LEEWAY CLAUSE FORM
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Investments Made and/or Required to be held under K.S.A. 40-2b13 (Life Companies) or K.S.A. 40-2a16 (Fire & Casualty Companies and Health Entities) during
the year ended December 31, 2015
Admitted assets December 31, previous year
x 10% =
(maximum amount to be held under K.S.A. 40-2b13 or K.S.A. 40-2a16)
(Companies that were newly formed during 2015 should utilize the admitted assets amount reported in their first financial statement filed with our Department.)
(Name and telephone number of individual responsible for completion of form)
Did the Company hold investments in Leeway as of December 31, 2015? Yes
No
If Yes, complete the chart below. If No, it is not necessary to complete
the chart below.
DESCRIPTION
DATE
MORTGAGE
80%
COST
EXCESS OR
REMARKS
(Provide a complete and
APPROVED
LOAN
OF
OF
AMOUNT
(Indicate whether the investment is
accurate description for each
BY BOARD
PRINCIPAL
APPRAISED
INVESTMENT
HELD UNDER
current as to principal and interest)
individual investment held in
OR
BALANCE
VALUE
LEEWAY
Leeway)
COMMITTEE
CLAUSE
Provide an explanation as to why each
individual investment is held in
Upload additional pages if
Leeway, including reference to the
necessary
statutory limitation
Mortgage Loans*
Bonds*
Stocks*
Other*
TOTALS
*To be listed in order as they appear in applicable investment schedule
Financial Surveillance
Leeway Clause Form.doc
11/2015
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