Page:Canada Gazette, June-December 1868.djvu/145



Statement to be made by a Fire or Guarantee Insurance Company whose deposits are under one hundred thousand dollars, except those referred to in section four.

$ cts.

Amount of Premiums received during the year on risks effected in Canada less twenty-five per cent. and the net amount of losses actually paid

Deposit in conformity with the second section of the said Act

Assets of the Company

Liabilities of the Company

Amount of Capital Stock

Amount paid thereon

Of what the assets of the Company consist, viz: (insert particulars)

Amount of losses paid during the year

Amount of losses due and unpaid

Losses adjusted and not due

Losses in suspense and waiting for further proof

Losses the payment of which is resisted, and for what cause

All other claims against the Company

Amount of premiums earned during the past year

Amount of premiums unearned

Amount at risk on total policies in force in Canada

Losses in Canada paid during the year

Losses in Canada adjusted and not due

Losses in suspense and waiting for further proof

Losses the payment of which is resisted and for what cause

All other claims against the Company

Premiums earned in Canada daring the year

Premiums unearned in Canada during the year

Statement to be made by an Insurance Company referred to Section fifteen.

$ cts.

Total premiums received during the year, in Canada

Number and amount of policies issued do. do.

Amount at risk in total policies in force in Canada

Number and amount of policies that have become claims in Canada during the year

Amount of losses in Canada paid during the year

Amount of losses in Canada in suspense and waiting further proof

Losses in Canada the payment of which is resisted and for what cause

Amount of premiums earned for the past year in Canada

Amount of premiums unearned in Canada