2018-06-14T09:47:20-05:00 2017-12-31 521446779 JOHNSON LAMBERT LLP 4242 SIX FORKS RD STE 1500 RALEIGH NC 27609 990 2017-01-01 820648671 PENN TREATY PROTECTED CELL OF LTC RE PENN 8028641711 1050 CONNECTICUT AVE NE NO 700 WASHINGTON DC 20036 BRENDA J CUSHING CFO 8028641711 2018-06-14 1 JOHN HUSKINS P01081531 9197196400 2018-06-14 2017 2022-09-23 18:48:47Z X BRENDA J CUSHING 1050 CONNECTICUT AVE NE NO 700 WASHINGTON DC 20036 3132810783 0 6262 X N/A X 2016 DC LTC RE IS A PROTECTED CELL CAPTIVE INSURANCE COMPANY FORMED BY THE NATIONAL ORGANIZATION OF LIFE AND HEALTH GUARANTY ASSOCIATIONS, WHOSE MEMBERS ARE LIFE AND HEALTH INSURANCE STATE GUARANTY ASSOCIATIONS AFFECTED BY THE INSOLVENCY OF PENN TREATY NETWORK AMERICA INSURANCE COMPANY AND/OR ITS WHOLLY OWNED SUBSIDIARY, AMERICAN NETWORK INSURANCE COMPANY. THE MEMBERS REINSURE THEIR OBLIGATIONS TO LTC RE TO SERVICE THE COVERED POLICYHOLDERS. 11 11 0 20 0 0 0 0 0 3003104583 0 38780376 0 0 0 3041884959 0 0 0 0 0 0 0 0 0 0 3030322123 0 3030322123 0 11562836 0 2870395453 0 2842073013 0 28322440 X LTC RE IS A PROTECTED CELL CAPTIVE INSURANCE COMPANY FORMED BY THE NATIONAL ORGANIZATION OF LIFE AND HEALTH GUARANTY ASSOCIATIONS, WHOSE MEMBERS ARE LIFE AND HEALTH INSURANCE STATE GUARANTY ASSOCIATIONS AFFECTED BY THE INSOLVENCY OF PENN TREATY NETWORK AMERICA INSURANCE COMPANY AND/OR ITS WHOLLY OWNED SUBSIDIARY, AMERICAN NETWORK INSURANCE COMPANY. THE MEMBERS REINSURE THEIR OBLIGATIONS TO LTC RE TO SERVICE THE COVERED POLICYHOLDERS.THE GUARANTY ASSOCIATIONS PROVIDE THE INSURANCE INDUSTRY AND ITS CONSUMERS WITH A SAFETY NET IN THE EVENT AN INSURANCE COMPANY BECOMES INSOLVENT AND UNABLE TO PAY CLAIMS. 0 0 THE GUARANTY ASSOCIATIONS PROVIDE THE INSURANCE INDUSTRY AND ITS CONSUMERS WITH A SAFETY NET IN THE EVENT AN INSURANCE COMPANY BECOMES INSOLVENT AND UNABLE TO PAY CLAIMS 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 X 11 11 0 1 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X BRENDA J CUSHING 8028641711 1050 CONNECTICUT AVE NW STE 700 WASHINGTON DC 20036 X ERIC RANGEN PRESIDENT 2.00 1.00 X X 0 0 0 PETER GALLANIS SECRETARY 1.00 1.00 X X 0 0 0 KEITH PASSWATER TREASURER 1.00 1.00 X X 0 0 0 AARON BALL DIRECTOR 1.00 1.00 X 0 0 0 SANDRA CALLAHAN DIRECTOR (TO NOV '17) 1.00 1.00 X 0 0 0 FREDERIC FUTTERMAN DIRECTOR 2.00 1.00 X 0 0 0 CHARLES GULLICKSON DIRECTOR 1.00 1.00 X 0 0 0 CARL MCDONALD DIRECTOR 1.00 1.00 X 0 0 0 PAMELA OLSEN DIRECTOR 1.00 1.00 X 0 0 0 MARGARET PARKER DIRECTOR 1.00 1.00 X 0 0 0 JOHN STENSON DIRECTOR (FROM NOV '17) 1.00 1.00 X 0 0 0 JAMES YABLECKI DIRECTOR 1.00 1.00 X 0 0 0 BRENDA CUSHING CHIEF FINANCIAL OFFICER 21.60 2.40 X 0 0 0 JOANNE ANATOLE CHIEF OPERATING OFFICER 16.20 1.80 X 0 0 0 0 0 0 0 0 0 0 PENN TREATY NETWORK AMERICA PO BOX 7066 ALLENTOWN PA 18105 THIRD PARTY ADMINISTRATOR 12193178 DRINKER BIDDLE & REATH 1500 K STREET NW STE 1100 WASHINGTON DC 20005 LEGAL SERVICES 718187 LONG TERM CARE GROUP 1210 NORTHBROOK DR STE 100 TREVOSE PA 19053 ACTUARIAL SERVICES 598264 WELLINGTON ASSET MANAGEMENT 280 CONGRESS ST BOSTON MA 02210 INVESTMENT MANAGEMENT 486534 BC CONSULTING 2816 JORDAN GROVE WEST DES MOINES IA 50265 FINANCIAL MANAGEMENT 416211 6 REINSURANCE PREMIUMS 900099 3003104583 3003104583 3003104583 38488253 38488253 91217947 90925824 292123 292123 292123 3041884959 3003104583 0 38780376 896157 743757 612766 765597 28094 5562 1440 280540 CHANGE IN RESERVES 2822125187 CLAIMS PAID 192578665 THIRD PARTY ADMINISTRAT 12193179 TAXES & LICENSES 91179 3030322123 0 0 49789098 0 2833313 0 470586162 0 56458 0 1262428995 0 1084701427 0 2870395453 0 827838 0 19119987 0 2822125188 0 2842073013 X 0 0 0 0 0 28322440 0 28322440 0 2870395453 X 11562836 16849604 -90000 X 0 1 X 1 0 0 ACCRUED INVESTMENT INCOME 15765478 FUNDS HELD IN TRUST BY RECEIVER 27516960 GUARANTY ASSOCIATION RECEIVABLES 1041418989 1084701427 POLICY RESERVES 2211975079 LAE RESERVES 24243776 CLAIMS RESERVES 585906333 2822125188 X PART X, LINE 2: MANAGEMENT HAS CONCLUDED THAT LTC RE, PTNA PC AND ANIC PC HAVE PROPERLY MAINTAINED THEIR FEDERAL AND STATE TAX-EXEMPT STATUS AND HAVE NOT TAKEN ANY UNCERTAIN TAX POSITIONS WHICH WOULD JEOPARDIZE ITS FEDERAL INCOME TAX-EXEMPT STATUS. BC CONSULTING LLC ENTITY OWNED MORE THAN 35% BY BRENDA CUSHING, CFO 416211 CFO MANAGEMENT SERVICES FOR GROUP 0 ENDEAVOUR CONSULTING LLC ENTITY OWNED MORE THAN 35% BY JOANNE ANATOLE, COO 112254 COO MANAGEMENT SERVICES FOR GROUP 0 FORM 990, PART VI, SECTION A, LINE 3 PTNA PC CONTRACTED WITH CONSULTANTS, PROFESSIONAL SERVICE PROVIDERS, AND THIRD PARTY ADMINISTRATORS TO PERFORM SUBSTANTIALLY ALL NECESSARY CLERICAL AND MANAGERIAL FUNCTIONS. FORM 990, PART VI, SECTION A, LINE 6 THE CAPTIVE HAS ONE CLASS OF MEMBERS. EACH LIFE & HEALTH INSURANCE GUARANTY ASSOCIATION LOCATED IN THE UNITED STATES WHO IS ALSO A MEMBER OF THE NATIONAL ORGANIZATION OF LIFE & HEALTH INSURANCE GUARANTY ASSOCIATIONS AND WHO WAS IMPACTED BY THE INSOLVENCY OF PENN TREATY NETWORK AMERICA INSURANCE COMPANY AND/OR ITS WHOLLY OWNED SUBSIDIARY, AMERICAN NETWORK INSURANCE COMPANY IS ELIGIBLE TO BECOME A MEMBER. FORM 990, PART VI, SECTION A, LINE 7A THE FOLLOWING INDIVIDUALS WILL BE DIRECTORS: CHAIR OF THE NOLHGA PTNA/ANIC TASK FORCE, CHAIR OF THE NOLHGA MEMBERS PARTICIPATION COUNCIL, AND THE PRESIDENT OF NOLHGA. FORM 990, PART VI, SECTION B, LINE 11B FORM 990 IS REVIEWED BY THE CHIEF FINANCIAL OFFICER, CHIEF OPERATING OFFICER, LEGAL COUNSEL, CAPTIVE MANAGER, AUDIT AND RISK ADVISORY COMMITTEE, AND BY THE BOARD OF DIRECTORS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C COVERED PERSONS ARE UNDER A CONTINUING OBLIGATION TO DISCLOSE ANY SITUATION THAT PRESENTS A CONFLICT OF INTEREST. ANY COVERED PERSON WHO BECOMES AWARE OF A CONFLICT OF INTEREST OR POTENTIAL CONFLICT OF INTEREST IS REQUIRED TO BRING IT TO THE ATTENTION OF AN EXECUTIVE OFFICER. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT PUBLICLY AVAILABLE. FORM 990, PART XI, LINE 9: CONTRIBUTED SURPLUS -90,000. LTC REINSURANCE PCC 1050 CONNECTICUT AVE NW STE 700 WASHINGTON DC 20036 812155730 MANAGEMENT COMPANY DC 501(C)(6) N/A 0 ANIC PROTECTED CELL OF LTC RE 1050 CONNECTICUT AVE NW STE 700 WASHINGTON DC 20036 820630879 REINSURANCE DC 501(C)(6) N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0