RFP%2031786-00193%20Appendix%207.19%20Detail%20Claims%20Listing%20_Voluntary_ADandD.xlsx

XLSX spreadsheet 93 KB Posted Aug 20, 2026

Attached to: Life and Accidental Death and Dismemberment Insurance - UPDATED
Solicitation number: RFP 31786-00193
Issued by: Davidson County, Tennessee

About this file

Written by GovTribe AI · Aug 21, 2026

This document is a detailed claims listing for Voluntary Accidental Death and Dismemberment (AD&D) insurance provided to Tennessee state employees under Policy Number 34295, issued as part of RFP 31786-00193. The file presents comprehensive claims experience data spanning from 2018 through the second quarter of 2026, tracking individual and dependent claims across multiple insurance plan categories including Employee, Single, Spouse, Child, Spouse & Child, Family, and Dependent coverage options. The document catalogs claim-by-claim details including claim numbers, claimant ages, dates of claim, notice received dates, payment dates, insurance amounts paid, interest paid, current reserves, prior reserves, and incurred claim totals for each reporting period.

The claims data reveals significant experience patterns across the eight-year period, with total insurance amounts paid ranging from zero in certain periods to $400,000 in 2023 for single employee claims. Notable claim trends include reserved amounts for unpaid claims, with the 2026 Q2 estimate period showing particularly high reserves totaling $798,000 across employee, spouse, and child categories, plus Incurred But Not Reported (IBNR) estimates of approximately $317,477. The largest individual claims noted include a $500,000 reserved amount for an employee claim in 2026 Q2 and a $300,000 reserved amount for a spouse claim in 2024. Interest paid on claims ranges from minimal amounts to over $2,700 in 2022, indicating varying settlement timelines. The data demonstrates the claims administration and financial experience underlying Tennessee's voluntary AD&D insurance program for state employees and their beneficiaries.

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Other files

File	Type	Posted
RFP_31786-00193_Appendix_7.28.pdf	PDF	Oct 14, 2026
RFP_31786-00193_Appendix_7.30.xlsx	XLSX spreadsheet	Oct 14, 2026
RFP_31786-00193_Life_and_ADD_RFP_Release_2.docx	DOCX document	Oct 14, 2026
RFP_31786-00193_Appendix_7.27.pdf	PDF	Oct 14, 2026
RFP_31786-00193_Appendix_7.15.xlsx	XLSX spreadsheet	Oct 14, 2026
RFP_31786-00193_Appendix_7.26.xlsx	XLSX spreadsheet	Oct 14, 2026
RFP_31786-00193_Appendix_7.29.pdf	PDF	Oct 14, 2026
RFP_31786-00193_Amendment_Two.docx	DOCX document	Oct 14, 2026
RFP_31786-00193_Appendix_7.4.xlsx	XLSX spreadsheet	Oct 14, 2026
RFP_31786-00193_Appendix_7.25.xlsx	XLSX spreadsheet	Oct 14, 2026
RFP_31786-00193_Appendix_7.5.xlsx	XLSX spreadsheet	Oct 14, 2026
RFP_31786-00193_Amendment_One_Schedule_Update.docx	DOCX document	Oct 2, 2026
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RFP%2031786-00193%20Appendix%207.14%20Voluntary%20Term%20Life%20Enrollment%20History%202018%20-%20June%202026.pdf	PDF	Aug 20, 2026
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31786-00193_Digital_Submission_Instructions.docx	DOCX document	Aug 20, 2026
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2018 Voluntary AD&D

RFP 31786-00193 Appendix 7.19 Detail Claims Listing – Voluntary AD&D

Nonparticipating Voluntary AD&D - Employee Claims Experience Policy Number: 34295

For the Period January 1, 2018 through December 31, 2018

	Accidental Death & Dismemberment Claims
	Claim Number		Age at
Claim						Date of
Claim				Date Notice
Received							Date
Paid							Insurance
Amount Paid								Interest
Paid							Current
Reserve					Prior
Reserve		Incurred

Claims

1206969	64	07/22/2016	06/12/2017		$ 0.00	$ 0.00	$ 0.00	$ 60,000.00	($ 60,000.00)
1335804	52	06/02/2018	06/18/2018	07/27/2018	60,000.00	90.41	0.00	0.00	60,090.41
1349416	69	04/07/2018	08/28/2018	09/05/2018	60,000.00	248.22	0.00	0.00	60,248.22
D092302	58	04/09/2018	04/26/2018	08/02/2018	30,000.00	95.83	0.00	0.00	30,095.83 (D)
			4	Total Claims	$ 150,000.00	$ 434.46	$ 0.00	$ 60,000.00	$ 90,434.46
(D) Dismemberment Benefit

Nonparticipating Voluntary AD&D - Dependent Claims Experience Policy Number: 34295 For the Period January 1, 2018 through December 31, 2018

	Accidental Death & Dismemberment Claims
	Claim Number		Age at
Claim						Date of
Claim				Date Notice
Received							Date
Paid							Insurance
Amount Paid								Interest
Paid							Current
Reserve					Prior
Reserve		Incurred

Claims

1336138	60	05/21/2018	06/19/2018	07/02/2018	$ 25,000.00	$ 28.77	$ 0.00	$ 0.00	$ 25,028.77
			1	Total Claim	$ 25,000.00	$ 28.77	$ 0.00	$ 0.00	$ 25,028.77

2019 Voluntary AD&D

Nonparticipating Voluntary AD&D - Employee Claims Experience Policy Number: 34295 For the Period January 1, 2019 through December 31, 2019

Accidental Death & Dismemberment Claims
Claim Number	Age at Claim	Date of Claim	Date Notice Received	Date Paid		Insurance Amount Paid		Interest Paid		Current Reserve		Prior Reserve		Incurred Claims
1381903	57	01/09/2019	02/14/2019	02/22/2019		$ 60,000.00		$ 72.33		$ 0.00		$ 0.00		$ 60,072.33
1417994	64	08/08/2019	10/17/2019	12/10/2019		63,000.00		215.11		0.00		0.00		63,215.11 *
1426656	32	09/05/2019	09/25/2019	01/28/2020		60,000.00		238.36		0.00		0.00		60,238.36
3					Total Claims	$	183,000.00	$	525.80	$	0.00	$	0.00	$	183,525.80
*Includes Additional AD&D Benefit

Nonparticipating Voluntary AD&D - Dependent Claims Experience Policy Number: 34295 For the Period January 1, 2019 through December 31, 2019

	Accidental Death & Dismemberment Claims
	Claim Number					Age at
Claim				Date of
Claim		Date Notice
Received				Date
Paid			Insurance
Amount Paid					Interest
Paid		Current
Reserve				Prior
Reserve		Incurred

Claims

1388945	33	02/26/2019	06/19/2019		$ 0.00	$ 0.00	$ 25,000.00	$ 0.00	$ 25,000.00
1395381	50	04/13/2019	05/07/2019	05/31/2019	36,000.00	47.34	0.00	0.00	36,047.34
1414409	61	07/24/2019	08/23/2019	08/27/2019	25,000.00	23.29	0.00	0.00	25,023.29
1424589	17	07/23/2019	09/23/2019	01/23/2020	5,000.00	25.21	0.00	0.00	5,025.21
1442332	23	11/22/2019	12/17/2019	12/31/2019	5,000.00	5.34	0.00	0.00	5,005.34
			5	Total Claims	$ 71,000.00	$ 101.18	$ 25,000.00	$ 0.00	$ 96,101.18

2020 Voluntary AD&D

Nonparticipating Voluntary AD&D - Employee Claims Experience Policy Number: 34295 For the Period January 1, 2020 through December 31, 2020

	Accidental Death & Dismemberment Claims
	Claim Number					Age at
Claim			Date of
Claim					Date Notice
Received				Date
Paid					Insurance
Amount Paid				Interest
Paid					Current
Reserve		Prior
Reserve		Incurred

Claims

1490562	60	07/28/2020	08/12/2020		$ 0.00	$ 0.00	$ 60,000.00	$ 0.00	$ 60,000.00
1505114	55	10/09/2020	10/21/2020		0.00	0.00	60,000.00	0.00	60,000.00
			2	Total Claims	$ 0.00	$ 0.00	$ 120,000.00	$ 0.00	$ 120,000.00

Nonparticipating Voluntary AD&D - Dependent Claims Experience Policy Number: 34295 For the Period January 1, 2020 through December 31, 2020

	Accidental Death & Dismemberment Claims
	Claim Number					Age at
Claim			Date of
Claim					Date Notice
Received				Date
Paid					Insurance
Amount Paid				Interest
Paid					Current
Reserve		Prior
Reserve		Incurred

Claims

1388945	33	02/26/2019	06/19/2019		$ 0.00	$ 0.00	$ 0.00	$ 25,000.00	$	(25,000.00)
1468138	68	04/01/2020	07/28/2020		0.00	0.00	36,000.00	0.00		36,000.00
1497773	21	09/14/2020	10/19/2020	12/30/2020	5,000.00	14.66	0.00	0.00		5,014.66
1509884	19	10/10/2020	11/12/2020	11/24/2020	5,500.00	6.78	0.00	0.00		5,506.78
1521509	25	11/10/2020	01/07/2021		0.00	0.00	5,000.00	0.00		5,000.00
			5	Total Claims	$ 10,500.00	$ 21.44	$ 41,000.00	$ 25,000.00	$	26,521.44
*Includes Additional AD&D Benefit

2021 Voluntary AD&D

Nonparticipating Voluntary AD&D - Single Insurance Claims Experience Policy Number: 34295 For the Period January 1, 2021 through September 30, 2021

	Claim Number	Age at
Claim		Date of
Claim	Date Notice
Received					Date
Paid			Insurance
Amount Paid			Interest
Paid				Current
Reserve			Prior
Reserve		Incurred

Claims

	1505114	55	10/09/2020	10/21/2020		0.00	0.00	$ 0.00	$ 60,000.00	($ 60,000.00)
	1546883	48	12/18/2020	04/09/2021		0.00	0.00	60,000.00	0.00	60,000.00
	1520183	60	12/08/2020	12/28/2020	05/03/2021	66,000.00	264.00	0.00	0.00	66,264.00 *
	1560252	66	06/02/2021	06/17/2021		0.00	0.00	60,000.00	0.00	60,000.00
	1549817	61	04/05/2021	04/23/2021	08/20/2021	66,000.00	247.73	0.00	0.00	66,247.73 *
	1517230	52	12/11/2020	07/07/2021		0.00	0.00	60,000.00	0.00	60,000.00
	1527282	50	10/27/2020	01/23/2021	07/08/2021	60,000.00	417.53	0.00	0.00	60,417.53
	1572281	49	08/04/2021	08/16/2021	08/18/2021	60,000.00	23.01	0.00	0.00	60,023.01
	1535077	59	10/25/2020	07/28/2021		0.00	0.00	60,000.00	0.00	60,000.00
	1490562	60	07/28/2020	08/12/2020		0.00	0.00	0.00	60,000.00	(60,000.00)
						$ 252,000.00	$ 952.27	$ 240,000.00	$ 120,000.00	$ 372,952.27
									IBNR	$ 10,782
		10	Total Claims							$ 383,734.27
* Includes Additional AD&D Benefit

Nonparticipating Voluntary AD&D - Family Insurance Claims Experience Policy Number: 34295 For the Period January 1, 2021 through September 30, 2021

		Claim Number	Age at
Claim			Date of
Claim		Date Notice
Received						Date
Paid				Insurance
Amount Paid					Interest
Paid					Current
Reserve					Prior
Reserve	Incurred

Claims

1468138	68	04/01/2020	07/28/2020		$ 0.00	$ 0.00	$ 0.00	$ 36,000.00	($ 36,000.00)
1521509	25	11/10/2020	01/07/2021		0.00	0.00	5,000.00	5,000.00	0.00
1524418	60	01/04/2021	02/23/2021	03/29/2021	36,000.00	82.85	0.00	0.00	36,082.85
1530392	56	01/11/2021	02/03/2021	04/02/2021	60,000.00	133.15	0.00	0.00	60,133.15
1532211	25	01/21/2021	02/17/2021	05/03/2021	5,000.00	13.97	0.00	0.00	5,013.97
1539322	20	12/26/2020	03/09/2021	04/12/2021	5,000.00	14.66	0.00	0.00	5,014.66
1548235	22	02/07/2021	04/16/2021	04/23/2021	5,000.00	10.27	0.00	0.00	5,010.27
1550198	17	04/15/2021	06/09/2021	06/30/2021	5,000.00	10.41	0.00	0.00	5,010.41
1554147	44	05/05/2021	05/24/2021		0.00	0.00	36,000.00	0.00	36,000.00
1556191	57	05/09/2021	08/16/2021		0.00	0.00	25,000.00	0.00	25,000.00
D115625	47	11/14/2020	04/05/2021	04/16/2021	12,500.00	52.40	0.00	0.00	12,552.40	(D)
					$ 128,500.00	$ 317.71	$ 66,000.00	$ 41,000.00	$ 153,817.71
								IBNR	$ 19,391
	11	Total Claims							$ 173,208.71

2022 Voluntary AD&D Nonparticipating Voluntary AD&D - Employee Claims Experience Policy Number: 34295 For the Period January 1, 2022 through December 31, 2022 Accidental Death & Dismemberment Claims

	Claim Number	Age at
Claim			Date of
Claim			Date Notice
Received				Date
Paid						Insurance
Amount Paid						Interest
Paid							Current
Reserve					Prior
Reserve				Incurred

Claims

1535077	59	10/25/2020	07/28/2021	08/22/2022	$	60,000.00	$	1,094.79	$	0.00	$	60,000.00	$	1,094.79
1611351	68	12/31/2021	03/10/2022	03/29/2022		60,000.00		144.66		0.00		0.00		60,144.66
1616554	67	10/26/2021	03/01/2022	06/03/2022		60,000.00		361.64		0.00		0.00		60,361.64
1627103	53	04/04/2022	04/21/2022	04/27/2022		60,000.00		37.81		0.00		0.00		60,037.81
1648999	49	07/09/2022	09/15/2022	10/14/2022		66,000.00		179.84		0.00		0.00		66,179.84 *
1658271	61	08/29/2022	12/09/2022			0.00		0.00		60,000.00		0.00		60,000.00
1667964	35	08/23/2022	12/09/2022			0.00		0.00		60,000.00		0.00		60,000.00
D122860	60	08/08/2019	07/15/2022	08/30/2022		30,000.00		928.42		0.00		0.00		30,928.42 (D)
			8	Total Claims	$	336,000.00	$	2,747.16	$	120,000.00	$	60,000.00	$	398,747.16
(D) Dismemberment Benefit
*Includes Additional AD&D Benefit
Nonparticipating Voluntary AD&D - Dependent Claims Experience Policy Number: 34295

For the Period January 1, 2022 through December 31, 2022 Accidental Death & Dismemberment Claims

	Claim Number			Age at
Claim		Date of
Claim				Date Notice
Received				Date
Paid					Insurance
Amount Paid							Interest
Paid						Current
Reserve						Prior
Reserve			Incurred

Claims

1521509	25	11/10/2020	01/07/2021		$	0.00	$	0.00	$	0.00	$	5,000.00	$	(5,000.00)
1554147	44	05/05/2021	05/24/2021			0.00		0.00		0.00		36,000.00		(36,000.00)
1554169	62	04/15/2021	03/10/2022			0.00		0.00		25,000.00		0.00		25,000.00
1567355	23	07/15/2021	07/19/2021			0.00		0.00		0.00		5,000.00		(5,000.00)
1581637	22	09/14/2021	11/05/2021			0.00		0.00		5,000.00		0.00		5,000.00
1586056	14	10/04/2021	03/18/2022	05/09/2022		5,000.00		29.73		0.00		0.00		5,029.73
1597075	25	08/30/2021	12/06/2021			0.00		0.00		0.00		5,000.00		(5,000.00)
1598002	17	11/10/2021	12/10/2021	08/17/2022		5,000.00		38.36		0.00		5,000.00		38.36
1631398	45	02/02/2022	05/18/2022			0.00		0.00		25,000.00		0.00		25,000.00
1635278	45	05/05/2022	06/07/2022			0.00		0.00		60,000.00		0.00		60,000.00
1639525	83	06/02/2022	06/30/2022	08/26/2022		60,000.00		139.73		0.00		0.00		60,139.73
1656435	18	09/27/2022	11/22/2022			0.00		0.00		5,000.00		0.00		5,000.00
1657578	58	10/04/2022	01/18/2023			0.00		0.00		25,000.00		0.00		25,000.00
1673042	67	12/19/2022	01/12/2023			0.00		0.00		36,000.00		0.00		36,000.00
			14	Total Claims	$	70,000.00	$	207.82	$	181,000.00	$	56,000.00	$	195,207.82

2023 Voluntary AD&D Nonparticipating Voluntary AD&D - Single Claims Experience Policy Number: 34295 For the Period January 1, 2023 through December 31, 2023 Accidental Death & Dismemberment Claims

	Claim Number			Age at
Claim		Date of
Claim			Date Notice
Received			Date
Paid					Insurance
Amount Paid						Interest
Paid				Current
Reserve				Prior
Reserve				Incurred

Claims

1658271	61	08/29/2022	12/09/2022	03/08/2023	$	60,000.00	$	290.96	$	0.00	$	60,000.00	$	290.96
1667964	35	08/23/2022	12/09/2022	02/13/2023		60,000.00		286.03		0.00		60,000.00		286.03
1684754	32	02/26/2023	05/02/2023			0.00		0.00		60,000.00		0.00		60,000.00
1687859	33	01/17/2023	03/22/2023	06/28/2023		60,000.00		266.30		0.00		0.00		60,266.30
1698042	49	04/13/2023	05/16/2023	08/08/2023		60,000.00		93.70		0.00		0.00		60,093.70
1699558	47	05/18/2023	06/12/2023	06/22/2023		100,000.00		95.88		0.00		0.00		100,095.88
1706525	53	07/03/2023	08/08/2023	08/22/2023		60,000.00		82.19		0.00		0.00		60,082.19
1710232	37	07/21/2023	11/08/2023			0.00		0.00		60,000.00		0.00		60,000.00
1727527	41	10/18/2023	11/02/2023			0.00		0.00		250,000.00		0.00		250,000.00
			9	Total Claims	$	400,000.00	$	1,115.06	$	370,000.00	$	120,000.00	$	651,115.06

Nonparticipating Voluntary AD&D - Spouse & Child Claims Experience Policy Number: 34295 For the Period January 1, 2023 through December 31, 2023 Accidental Death & Dismemberment Claims

	Age at	Date of	Date Notice	Date	Insurance	Interest	Current	Prior	Incurred
Claim Number	Claim	Claim	Received	Paid	Amount Paid	Paid	Reserve	Reserve	Claims
NONE

Nonparticipating Voluntary AD&D - Spouse Claims Experience Policy Number: 34295 For the Period January 1, 2023 through December 31, 2023 Accidental Death & Dismemberment Claims

	Claim Number			Age at
Claim		Date of
Claim			Date Notice
Received			Date
Paid				Insurance
Amount Paid						Interest
Paid					Current
Reserve				Prior
Reserve			Incurred

Claims

1734596	65	11/08/2023	12/12/2023		$ 0.00	$ 0.00	$ 36,000.00	$ 0.00	$ 36,000.00
			1	Total Claim	$ 0.00	$ 0.00	$ 36,000.00	$ 0.00	$ 36,000.00

Nonparticipating Voluntary AD&D - Child Claims Experience Policy Number: 34295 For the Period January 1, 2023 through December 31, 2023 Accidental Death & Dismemberment Claims

	Claim Number			Age at
Claim		Date of
Claim			Date Notice
Received			Date
Paid					Insurance
Amount Paid						Interest
Paid				Current
Reserve				Prior
Reserve				Incurred

Claims

1683057	23	02/07/2023	05/16/2023		$	0.00	$	0.00	$	10,000.00	$	$	10,000.00
1683737	22	02/13/2023	02/28/2023	05/02/2023		6,000.00		12.82		0.00			6,012.82
1702677	21	05/19/2023	06/12/2023	09/29/2023		6,000.00		21.86		0.00			6,021.86
1720111	24	08/21/2023	09/21/2023	10/05/2023		6,000.00		7.40		0.00			6,007.40
1724069	21	10/02/2023	11/06/2023			0.00		0.00		6,000.00			6,000.00
1731392	24	11/04/2023	12/07/2023			0.00		0.00		6,000.00			6,000.00
			6	Total Claims	$	18,000.00	$	42.08	$	22,000.00	$	$	40,042.08

Nonparticipating Voluntary AD&D - Family Claims Experience Policy Number: 34295 For the Period January 1, 2023 through December 31, 2023 Accidental Death & Dismemberment Claims

	Claim Number			Age at
Claim		Date of
Claim			Date Notice
Received			Date
Paid				Insurance
Amount Paid						Interest
Paid					Current
Reserve				Prior
Reserve			Incurred

Claims

1554169	62	04/15/2021	03/10/2022		$ 0.00	$ 0.00	$ 0.00	$ 25,000.00	($ 25,000.00)
1581637	22	09/14/2021	11/05/2021		0.00	0.00	0.00	5,000.00	(5,000.00)
1631398	45	02/02/2022	05/18/2022		0.00	0.00	0.00	25,000.00	(25,000.00)
1635278	45	05/05/2022	06/07/2022	02/03/2023	60,000.00	450.41	0.00	60,000.00	450.41
1656435	18	09/27/2022	11/22/2022		0.00	0.00	0.00	5,000.00	(5,000.00)
1657578	58	10/04/2022	01/18/2023	02/06/2023	25,000.00	85.62	0.00	25,000.00	85.62
1659108	21	10/08/2022	10/18/2022	10/19/2023	5,000.00	29.45	0.00	0.00	5,029.45
1673042	67	12/19/2022	01/12/2023	02/27/2023	36,000.00	69.04	0.00	36,000.00	69.04
			8	Total Claims	$ 126,000.00	$ 634.52	$ 0.00	$ 181,000.00	($ 54,365.48)

2024 Voluntary AD&D Nonparticipating Voluntary AD&D - Single Claims Experience Policy Number: 34295 For the Period January 1, 2024 through December 31, 2024 Accidental Death & Dismemberment Claims

	Claim Number	Age at
Claim		Date of
Claim		Date Notice
Received				Date
Paid			Insurance
Amount Paid					Interest
Paid				Current
Reserve			Prior
Reserve				Incurred

Claims

1662615	77	10/04/2022	09/23/2024		$	0.00	$	0.00	$	60,000.00	$	0.00	$	60,000.00
1684754	32	02/26/2023	05/02/2023	07/01/2024		60,000.00		0.00		0.00		60,000.00		0.00
1710232	37	07/21/2023	11/08/2023			0.00		0.00		0.00		60,000.00		(60,000.00)
1727527	41	10/18/2023	11/02/2023	03/01/2024		250,000.00		461.60		0.00		250,000.00		461.60
1786466	48	08/15/2024	11/12/2024			0.00		0.00		60,000.00		0.00		60,000.00
1787050	44	08/31/2024	09/25/2024	10/04/2024		60,000.00		27.88		0.00		0.00		60,027.88
1793154	61	08/25/2024	10/30/2024			0.00		0.00		60,000.00		0.00		60,000.00
			7	Total Claims	$	370,000.00	$	489.48	$	180,000.00	$	370,000.00	$	180,489.48

Nonparticipating Voluntary AD&D - Spouse & Child Claims Experience Policy Number: 34295 For the Period January 1, 2024 through December 31, 2024 Accidental Death & Dismemberment Claims

	Age at	Date of	Date Notice	Date	Insurance	Interest	Current	Prior	Incurred
Claim Number	Claim	Claim	Received	Paid	Amount Paid	Paid	Reserve	Reserve	Claims
NONE

Nonparticipating Voluntary AD&D - Spouse Claims Experience Policy Number: 34295 For the Period January 1, 2024 through December 31, 2024 Accidental Death & Dismemberment Claims

	Claim Number	Age at
Claim		Date of
Claim		Date Notice
Received				Date
Paid			Insurance
Amount Paid					Interest
Paid				Current
Reserve			Prior
Reserve			Incurred

Claims

1734596	65	11/08/2023	12/12/2023	05/03/2024	$	60,000.00	$	145.29	$	0.00	$	36,000.00	$	24,145.29
1756723	60	02/21/2024	04/05/2024	06/17/2024		36,000.00		57.60		0.00		0.00		36,057.60
1759838	63	04/04/2024	04/23/2024			0.00		0.00		300,000.00		0.00		300,000.00
1779253	49	07/14/2024	08/12/2024	10/01/2024		40,000.00		42.11		0.00		0.00		40,042.11
1800970	55	10/20/2024	12/13/2024	01/16/2025		36,000.00		43.32		0.00		0.00		36,043.32
			5	Total Claims	$	172,000.00	$	288.32	$	300,000.00	$	36,000.00	$	436,288.32

Nonparticipating Voluntary AD&D - Child Claims Experience Policy Number: 34295 For the Period January 1, 2024 through December 31, 2024 Accidental Death & Dismemberment Claims

	Claim Number	Age at
Claim		Date of
Claim		Date Notice
Received				Date
Paid		Insurance
Amount Paid					Interest
Paid				Current
Reserve			Prior
Reserve		Incurred

Claims

1683057	23	02/07/2023	05/16/2023		$ 0.00	$ 0.00	$ 0.00	$ 10,000.00	($ 10,000.00)
1724069	21	10/02/2023	11/06/2023		0.00	0.00	0.00	6,000.00	(6,000.00)
1731392	24	11/04/2023	12/07/2023		0.00	0.00	0.00	6,000.00	(6,000.00)
1774859	19	03/22/2024	07/18/2024	07/24/2024	6,000.00	10.18	0.00	0.00	6,010.18
1790423	23	10/12/2024	10/14/2024		0.00	0.00	6,000.00	0.00	6,000.00
			5	Total Claims	$ 6,000.00	$ 10.18	$ 6,000.00	$ 22,000.00	($ 9,989.82)

2025 Voluntary AD&D Nonparticipating Voluntary AD&D - Single Claims Experience Policy Number: 34295 For the Period January 1, 2025 through December 31, 2025 Accidental Death & Dismemberment Claims

	Claim Number	Age at
Claim	Date of
Claim		Date Notice
Received			Date
Paid				Insurance
Amount Paid					Interest
Paid			Current
Reserve		Prior
Reserve			Incurred

Claims

1662615	77	10/04/2022	09/23/2024		$	0.00	$	0.00	$	0.00	$	60,000.00	$	(60,000.00)
1786466	48	08/15/2024	11/12/2024	05/02/2025		60,000.00		155.98		0.00		60,000.00		155.98
1793154	61	08/25/2024	10/30/2024			0.00		0.00		0.00		60,000.00		(60,000.00)
1850727	60	07/25/2025	08/19/2025	12/16/2025		60,000.00		118.18		0.00		0.00		60,118.18
1876134	41	12/04/2025	01/09/2026			0.00		0.00		60,000.00		0.00		60,000.00
1878901	67	08/15/2025	01/21/2026			0.00		0.00		60,000.00		0.00		60,000.00
			6	Total Claims	$	120,000.00	$	274.16	$	120,000.00	$	180,000.00	$	60,274.16

Nonparticipating Voluntary AD&D - Spouse & Child Claims Experience Policy Number: 34295 For the Period January 1, 2025 through December 31, 2025 Accidental Death & Dismemberment Claims

	Age at	Date of	Date Notice	Date	Insurance	Interest	Current	Prior	Incurred
Claim Number	Claim	Claim	Received	Paid	Amount Paid	Paid	Reserve	Reserve	Claims
NONE

Nonparticipating Voluntary AD&D - Spouse Claims Experience Policy Number: 34295 For the Period January 1, 2025 through December 31, 2025 Accidental Death & Dismemberment Claims

	Claim Number	Age at
Claim	Date of
Claim		Date Notice
Received			Date
Paid		Insurance
Amount Paid				Interest
Paid			Current
Reserve		Prior
Reserve			Incurred

Claims

1759838	63	04/04/2024	04/23/2024		$ 0.00	$ 0.00	$ 0.00	$ 300,000.00	($ 300,000.00)
			1	Total Claim	$ 0.00	$ 0.00	$ 0.00	$ 300,000.00	($ 300,000.00)

Nonparticipating Voluntary AD&D - Child Claims Experience Policy Number: 34295 For the Period January 1, 2025 through December 31, 2025 Accidental Death & Dismemberment Claims

	Claim Number	Age at
Claim	Date of
Claim		Date Notice
Received			Date
Paid				Insurance
Amount Paid					Interest
Paid			Current
Reserve		Prior
Reserve			Incurred

Claims

1731392	24	11/04/2023	12/07/2023	05/12/2025	$	6,000.00	$	45.68	$	$	0.00	$	6,045.68
1790423	23	10/12/2024	10/14/2024			0.00		0.00			6,000.00		(6,000.00)
1811229	17	12/31/2024	02/05/2025	04/04/2025		6,000.00		7.71			0.00		6,007.71
1817043	22	02/06/2025	03/03/2025	03/06/2025		50,000.00		19.13			0.00		50,019.13
1820635	18	11/11/2024	03/19/2025	07/11/2025		6,000.00		19.87			0.00		6,019.87
			5	Total Claims	$	68,000.00	$	92.39	$	$	6,000.00	$	62,092.39

2026 Q2 Voluntary AD&D Nonparticipating Voluntary AD&D - Employee Insurance Claims Experience Policy Number: 34295 For the Period January 1, 2026 through June 30, 2026 Estimate Accidental Death & Dismemberment Claims

		Claim Number	Age at
Claim	Sex			Date of
Claim						Date Notice
Received					Date
Paid						Insurance
Amount Paid						Interest
Paid							Current
Reserve								Prior
Reserve				Incurred

Claims

1876134	41	F	12/04/2025	01/09/2026		$ 0.00	$ 0.00	$ 60,000.00	$ 60,000.00	$ 0.00
1878901	67	F	08/15/2025	01/21/2026		0.00	0.00	60,000.00	60,000.00	0.00
1879878	65	F	08/08/2025	01/27/2026		0.00	0.00	100,000.00	0.00	100,000.00
1885205	23	F	02/07/2026	02/20/2026	02/26/2026	50,000.00	12.98	0.00	0.00	50,012.98
1890151	35	M	02/25/2026	03/17/2026	04/10/2026	250,000.00	150.35	0.00	0.00	250,150.35
1900508	50	F	04/23/2026	05/11/2026		0.00	0.00	60,000.00	0.00	60,000.00
1900815	62	M	02/07/2026	05/13/2026		0.00	0.00	500,000.00	0.00	500,000.00
						$ 300,000.00	$ 163.33	$ 780,000.00	$ 120,000.00	$ 960,163.33
									IBNR	$ 255,754
		7	Total Claims							$ 1,215,917.33

Nonparticipating Voluntary AD&D - Spouse & Child Insurance Claims Experience Policy Number: 34295 For the Period January 1, 2026 through June 30, 2026 Estimate Accidental Death & Dismemberment Claims

		Age at		Date of	Date Notice	Date	Insurance	Interest	Current	Prior	Incurred
	Claim Number	Claim	Sex	Claim	Received	Paid	Amount Paid	Paid	Reserve	Reserve	Claims
	NONE
IBNR $ 29,754
0 Total Claims $ 29,754.00

Nonparticipating Voluntary AD&D - Spouse Insurance Claims Experience Policy Number: 34295 For the Period January 1, 2026 through June 30, 2026 Estimate Accidental Death & Dismemberment Claims

		Claim Number	Age at
Claim	Sex			Date of
Claim					Date Notice
Received							Date
Paid				Insurance
Amount Paid					Interest
Paid						Current
Reserve								Prior
Reserve				Incurred

Claims

1897138	47	M	11/10/2025	05/04/2026	$ 0.00	$ 0.00	$ 18,000.00	$ 0.00	$ 18,000.00
					$ 0.00	$ 0.00	$ 18,000.00	$ 0.00	$ 18,000.00
								IBNR	$ 30,332
		1	Total Claim						$ 48,332.00

Nonparticipating Voluntary AD&D - Child Insurance Claims Experience Policy Number: 34295 For the Period January 1, 2026 through June 30, 2026 Estimate Accidental Death & Dismemberment Claims

		Age at		Date of	Date Notice	Date	Insurance	Interest	Current	Prior	Incurred
	Claim Number	Claim	Sex	Claim	Received	Paid	Amount Paid	Paid	Reserve	Reserve	Claims
	NONE
IBNR $ 21,637
0 Total Claims $ 21,637.00

File details come from the government source that posted it. Updated Aug 21, 2026.