Exhibit C - City of Madison Experience Report Jan 2021 - Apr 2026.pdf

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Attached to
Life and Disability Insurance
Solicitation number
15001-0-2026-BG
Issued by
Dane County, Wisconsin

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Written by GovTribe AI ·

This is a Hartford Life Insurance experience report for the City of Madison covering the period January 1, 2021, through April 9, 2026. The document details claims and premium data across multiple insurance coverage types managed under policy number 033731G, with sales representation by Kara Norman and service representation by Steven Sherman through the Chicago sales office.

The report encompasses five experience units covering Basic Life Insurance, Life Insurance with dependent coverage, Voluntary Life Insurance, Supplemental Life Insurance, Survivor Income Insurance for police and fire personnel, Short-Term Disability Insurance, and Long-Term Disability Insurance with Ability Assurance provisions. The consolidated account summary reflects total estimated earned premiums of $24,055,052.55 across all coverage types during the reporting period, with corresponding claims paid totaling $13,326,451.87. Short-Term Disability generated the highest claims volume at $6,345,308.34, followed by Basic Life Insurance at $3,190,500.00. The policy maintains active status with a 31-day grace period and has been in effect since February 1, 1990, with the current case effective date of February 1, 1993. No payments were applied to the period or estimated as due and unpaid, indicating the account was current as of the report run date of April 9, 2026.

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Customer Statement

Hartford Life, Inc. - Group Benefits Division

CITY OF MADISON

Policy Number: 033731G Experience Unit: 001 Experience Group: ALL AFT METRO EES (STD & LTD)

Policy Effective Date: 02/01/1993 Current Policy Status: ACTIVE Billing System:GIPR

Sales office: CHICAGO Sales Representative: KARA NORMAN Service Representative: STEVEN SHERMAN

Case Effective Date: 02/01/1990 Current Case Status: ACTIVE Grace Period: 31 Days

LIFE Basic PAR $0.00 $0.00 $0.00 $144,000.00

LIFE Interest $0.00 $0.00 $0.00 $82.35

Total: $0.00 $0.00 $0.00 $144,082.35

Long Term Disability PAR EXCEPTION $0.00 $0.00 $0.00 $107,012.40

Long Term Disability - Ability Assurance PAR EXCEPTION $1,597,617.67 $0.00 $1,597,617.67 $548,781.80

Long Term Disability Expenses $0.00 $0.00 $0.00 $35,285.96

Total: $1,597,617.67 $0.00 $1,597,617.67 $691,080.16

Short Term Disability PAR $3,939,625.20 $0.00 $3,939,625.20 $4,020,717.37

Short Term Disability Expenses $0.00 $0.00 $0.00 $10,760.97

Total: $3,939,625.20 $0.00 $3,939,625.20 $4,031,478.34

Grand Total: $5,537,242.87 $0.00 $5,537,242.87 $4,866,640.85

Rating Method Payments Applied to Period Estimated Due &

Unpaid Payments Estimated Earned premium Claims Paid in period

January 01,2021 through April 09,2026 Account Summary

Run Date: Page 1 of 7 GBD Information Services

Hartford Life 4/9/2026

Exhibit C

CITY OF MADISON

Policy Number: 033731G Experience Unit: 002 Experience Group: ALL OTH. (LIFE)

Policy Effective Date: 02/01/1993 Current Policy Status: ACTIVE Billing System:GIPR

Sales office: CHICAGO Sales Representative: KARA NORMAN Service Representative: STEVEN SHERMAN

Case Effective Date: 02/01/1990 Current Case Status: ACTIVE Grace Period: 31 Days

LIFE Basic PAR $3,062,864.97 $0.00 $3,062,864.97 $3,046,500.00

LIFE Basic Dependent PAR $249,775.75 $0.00 $249,775.75 $215,000.00

LIFE Interest $0.00 $0.00 $0.00 $1,905.91

LIFE Voluntary PAR $2,051,405.54 $0.00 $2,051,405.54 $1,474,000.00

Total: $5,364,046.26 $0.00 $5,364,046.26 $4,737,405.91

Long Term Disability PAR EXCEPTION $0.00 $0.00 $0.00 $220,525.15

Long Term Disability - Ability Assurance PAR EXCEPTION $0.00 $0.00 $0.00 $100,775.46

Long Term Disability Expenses $0.00 $0.00 $0.00 $2,164.50

Total: $0.00 $0.00 $0.00 $323,465.11

Short Term Disability PAR $0.00 $0.00 $0.00 $163,884.24

Total: $0.00 $0.00 $0.00 $163,884.24

Grand Total: $5,364,046.26 $0.00 $5,364,046.26 $5,224,755.26

Rating Method Payments Applied to Period Estimated Due &

Unpaid Payments Estimated Earned premium Claims Paid in period

January 01,2021 through April 09,2026 Account Summary

Run Date: Page 2 of 7 GBD Information Services

Hartford Life

CITY OF MADISON

Policy Number: 033731G Experience Unit: 005 Experience Group: ADITIONAL LIFE

Policy Effective Date: 02/01/1993 Current Policy Status: ACTIVE Billing System:GIPR

Sales office: CHICAGO Sales Representative: KARA NORMAN Service Representative: STEVEN SHERMAN

Case Effective Date: 02/01/1990 Current Case Status: ACTIVE Grace Period: 31 Days

LIFE Basic PAR $1,281,992.65 $0.00 $1,281,992.65 $0.00

Total: $1,281,992.65 $0.00 $1,281,992.65 $0.00

Grand Total: $1,281,992.65 $0.00 $1,281,992.65 $0.00

Rating Method Payments Applied to Period Estimated Due &

Unpaid Payments Estimated Earned premium Claims Paid in period

January 01,2021 through April 09,2026 Account Summary

Run Date: Page 3 of 7 GBD Information Services

Hartford Life

CITY OF MADISON

Policy Number: 033731G Experience Unit: Experience Group: PTD-CLMS-POLICEMEN/FIREMEN

Policy Effective Date: 02/01/1993 Current Policy Status: ACTIVE Billing System:GIPR

Sales office: CHICAGO Sales Representative: KARA NORMAN Service Representative: STEVEN SHERMAN

Case Effective Date: 02/01/1990 Current Case Status: ACTIVE Grace Period: 31 Days

LIFE Survivor Income NON PAR $0.00 $0.00 $0.00 $1,085,110.00

Total: $0.00 $0.00 $0.00 $1,085,110.00

Grand Total: $0.00 $0.00 $0.00 $1,085,110.00

Rating Method Payments Applied to Period Estimated Due &

Unpaid Payments Estimated Earned premium Claims Paid in period

January 01,2021 through April 09,2026 Account Summary

Run Date: Page 4 of 7 GBD Information Services

Hartford Life

CITY OF MADISON

Policy Number: 033731G Experience Unit: 007 Experience Group: ALL OTH. (ADD & DISABILITY)

Policy Effective Date: 02/01/1993 Current Policy Status: ACTIVE Billing System:GIPR

Sales office: CHICAGO Sales Representative: KARA NORMAN Service Representative: STEVEN SHERMAN

Case Effective Date: 02/01/1990 Current Case Status: ACTIVE Grace Period: 31 Days

LIFE Supplemental PAR $5,680,547.62 $0.00 $5,680,547.62 $0.00

Total: $5,680,547.62 $0.00 $5,680,547.62 $0.00

Long Term Disability - Ability Assurance PAR EXCEPTION $1,868,441.12 $0.00 $1,868,441.12 $0.00

Total: $1,868,441.12 $0.00 $1,868,441.12 $0.00

Short Term Disability PAR $4,322,782.03 $0.00 $4,322,782.03 $2,143,798.29

Short Term Disability Expenses $0.00 $0.00 $0.00 $6,147.47

Total: $4,322,782.03 $0.00 $4,322,782.03 $2,149,945.76

Grand Total: $11,871,770.77 $0.00 $11,871,770.77 $2,149,945.76

Rating Method Payments Applied to Period Estimated Due &

Unpaid Payments Estimated Earned premium Claims Paid in period

January 01,2021 through April 09,2026 Account Summary

Run Date: Page 5 of 7 GBD Information Services

Hartford Life

CITY OF MADISON

Policy Number:ALL

Experience Group: ALL Current Policy Status: ACTIVE Billing System:GIPR

Sales office: CHICAGO Sales Representative: KARA NORMAN Service Representative: STEVEN SHERMAN

Case Effective Date: 02/01/1990 Current Case Status: ACTIVE Grace Period: 31 Days

Rating Method Payments Applied to Period

Estimated Due & Unpaid Payments

Estimated Earned premium

Claims Paid in period

LIFE Basic PAR $4,344,857.62 $0.00 $4,344,857.62 $3,190,500.00 LIFE Basic Dependent PAR $249,775.75 $0.00 $249,775.75 $215,000.00 LIFE Interest $0.00 $0.00 $0.00 $1,988.26 LIFE Supplemental PAR $5,680,547.62 $0.00 $5,680,547.62 $0.00 LIFE Survivor Income NON PAR $0.00 $0.00 $0.00 $1,085,110.00 LIFE Voluntary PAR $2,051,405.54 $0.00 $2,051,405.54 $1,474,000.00

Total: $12,326,586.53 $0.00 $12,326,586.53 $5,966,598.26

Long Term Disability PAR EXCEPTION $0.00 $0.00 $0.00 $327,537.55 Long Term Disability - Ability Assurance PAR EXCEPTION $3,466,058.79 $0.00 $3,466,058.79 $649,557.26 Long Term Disability Expenses $0.00 $0.00 $0.00 $37,450.46

Total: $3,466,058.79 $0.00 $3,466,058.79 $1,014,545.27

Short Term Disability PAR $8,262,407.23 $0.00 $8,262,407.23 $6,328,399.90 Short Term Disability Expenses $0.00 $0.00 $0.00 $16,908.44

Total: $8,262,407.23 $0.00 $8,262,407.23 $6,345,308.34

January 01,2021 through April 09,2026 Account Summary

Grand Total: $24,055,052.55 $0.00 $24,055,052.55 $13,326,451.87

End Of Report

Run Date: Page 6 of 7 GBD Information Services

Hartford Life

End of the Report

Run Date: Page 7 of 7 GBD Information Services

Hartford Life

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File details come from the government source that posted it. Updated .