BETWEEN

EXHIBIT 10.3

COINSURANCE AGREEMENT

BETWEEN

PRINCIPAL MUTUAL LIFE INSURANCE COMPANY

DES MOINES, IOWA

AND

COVENTRY HEALTH AND LIFE INSURANCE COMPANY

XXXX XXXXX, XXXXX

TABLE OF CONTENTS

Page
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ARTICLE I DEFINITIONS.......................................................................... 1

ARTICLE II COVERAGE............................................................................. 3

ARTICLE III GENERAL PROVISIONS................................................................... 5

ARTICLE IV REINSURANCE PREMIUM.................................................................. 7

ARTICLE V RESERVES............................................................................. 8

ARTICLE VI EXPENSE ALLOWANCES................................................................... 8

ARTICLE VII ACCOUNTING AND SETTLEMENT............................................................ 9

ARTICLE VIII DURATION AND TERMINATION............................................................. 10

ARTICLE IX INSOLVENCY........................................................................... 11

ARTICLE X WITHHELD FUNDS....................................................................... 12

ARTICLE XI ARBITRATION.......................................................................... 13

ARTICLE XII MISCELLANEOUS PROVISIONS............................................................. 14

SCHEDULES

SCHEDULE A - TAX ELECTION

SCHEDULE B - REINSURANCE REPORTS

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COINSURANCE AGREEMENT

This Agreement, dated as of _________, 1998 (this "Agreement")
is made and entered into by and between Principal Mutual Life Insurance Company,
a corporation organized under the laws of the State of Iowa (hereinafter
referred to as the "Company"), and Coventry Health and Life Insurance Company, a
corporation organized under the laws of the State of Texas (hereinafter referred
to as the "Reinsurer").

The Company and the Reinsurer mutually agree to reinsure under
the terms and conditions stated herein. This Agreement is an indemnity
reinsurance agreement solely between the Company and the Reinsurer, and the
performance of the obligations of each party under this Agreement shall be
rendered solely to the other party. In no instance, except as set forth in
Article IX of this Agreement, shall anyone other than the Company or the
Reinsurer have any rights under this Agreement. The Company shall be and shall
remain the only party hereunder that is liable to any insured, policyholder or
beneficiary under any insurance policy or contract reinsured hereunder.

This Agreement is entered into pursuant to the terms and
conditions of the Merger Agreement (as hereinafter defined).

ARTICLE I

DEFINITIONS

1.1. Definitions. As used in this Agreement, the following
terms shall have the following meanings (definitions are applicable to both the
singular and the plural forms of each term defined in this Article):

"Accounting Period" means the calendar quarter.

"Agreement" shall have the meaning specified in the Recitals.

"Annual Report" shall have the meaning specified in Section
7.4.

"Business Day" means any day that is not a Saturday, Sunday or
a day banks in the State of Iowa are authorized or required to close.

"Code" means the Internal Revenue Code of 1986, as amended.

"Merger Agreement" means the Capital Contribution and Merger
Agreement (executed as of November 3, 1997, and amending and restating the
Capital Contribution and Share Exchange Agreement dated November 3, 1997),
entered into by and between the Company, Principal Health Care, Inc., Principal
Holding Company, Coventry Corporation, Coventry Health Care, Inc. (a Delaware
corporation), and Coventry Health Care, Inc. (a Maryland corporation) executed
on December __, 1997.

"Inception Date" shall have the meaning specified in Section
2.1.

"Initial Expense Allowance" shall have the meaning specified
in Section 6.1.

"Initial Reinsurance Premium" shall have the meaning specified
in Section 4.1.

"Initial Report" shall have the meaning specified in Section
7.2.

"Net Premiums" shall have the meaning specified in Section
4.1.

"Policy Premiums" shall have the meaning specified in Section
4.2.

"Quarterly Expense Allowances" shall have the meaning
specified in Section 6.1.

"Quarterly Report" shall have the meaning specified in Section
7.3.

"Quarterly Settlement" shall have the meaning set forth in
Section 7.1.

"Reinsured Policies" means the indemnity health insurance
policies issued by the Company and defined in the Merger Agreement as the Mutual
Indemnity Agreements.

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"Reinsured Risks" shall have the meaning specified in Section
2.1.

"SAP" means statutory accounting practices prescribed or
permitted by the Bureau of Insurance of the State of Iowa.

"Total Ceded Reserves" means the gross loss, loss adjustment
expense and unearned premium reserves of the Company calculated in accordance
with SAP with respect to the Reinsured Risks.

"Ultimate Net Loss" shall have the meaning specified in
Section 2.2.

"Umpire" shall have the meaning specified in Article XI.

"Unearned Premium Reserve" means the unearned premium reserve
of the Company with respect to the Reinsured Policies, determined in accordance
with SAP.

"Withheld Funds" shall have the meaning specified in Article
X.

ARTICLE II

COVERAGE

2.1. Coverage. As of 12:01 a.m. Central Time, on January 1,
2000 (the "Inception Date"), the Company agrees to reinsure with the Reinsurer,
and the Reinsurer agrees to indemnify the Company for, (a) all Ultimate Net Loss
incurred by the Company under the Reinsured Policies for losses and loss
adjustment expenses occurring on or after such date and (b) unearned premiums
returned to policyholders upon the cancellation of Reinsured Policies on or
after such date (the "Reinsured Risks").

2.2. Ultimate Net Loss. (a) "Ultimate Net Loss" shall mean (i)
the actual benefit or loss paid by the Company after making deductions for all
salvage, subrogations and

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other recoveries, plus (ii) loss adjustment expenses incurred in conjunction
with the payment of benefits or losses.

(b) Ultimate Net Loss shall not include any amount paid by the
Company for any extra-contractual obligations (including but not limited to
punitive damages, bad faith damages or compensatory damages) which may arise
from the acts or omissions of the Company in its conduct with its own insured or
policyholder, the beneficiary or assignee of any policy or any other person.
Notwithstanding the foregoing, Ultimate Net Loss will include extra-contractual
obligations where the Reinsurer is an active party and directs, consents to, or
ratifies the act, omission, or course of conduct that ultimately results in
assessment of such extra-contractual obligations, to the extent that such
Ultimate Net Loss is properly allocable between the parties based on relative
fault.

(c) All recoveries or payments received by the Company
subsequent to a benefit or loss settlement under this Agreement shall be applied
as if recovered or received prior to the aforesaid settlement and all necessary
adjustments shall be made by the parties hereto, provided that nothing in this
Section 2.2(c) shall be construed to mean that losses under this Agreement are
not recoverable until the Company's loss has been ascertained.

2.3. Territory. The territorial limits of this Agreement shall
be identical with those of the Reinsured Policies.

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ARTICLE III

GENERAL PROVISIONS

3.1. Contract Administration. Unless otherwise agreed by the
parties, the Company shall exclusively administer the Reinsured Policies and
perform all accounting for the Reinsured Policies. All claims or loss
settlements made by the Company shall be binding upon the Reinsurer.

3.2. Inspection. (a) The Reinsurer or its designated
representative may inspect, at the offices of the Company where such records are
located, the papers and any and all other books or documents of the Company
reasonably relating to the Reinsured Policies, during normal business hours for
such period as this Agreement is in effect or for as long thereafter as the
Company seeks performance by the Reinsurer pursuant to the terms of this
Agreement. The information obtained shall be used only for purposes relating to
reinsurance under this Agreement.

(b) The Company or its designated representative may inspect,
at the offices of the Reinsurer where such records are located, the papers and
any and all other books or documents of the Reinsurer reasonably relating to the
Reinsured Policies, during normal business hours for such period as this
Agreement is in effect or for as long thereafter as the Reinsurer seeks
performance by the Company pursuant to the terms of this Agreement. The
information obtained shall be used only for purposes relating to reinsurance
under this Agreement.

3.3. Misunderstandings and Oversights. If any delay, omission,
error or failure to pay amounts due or to perform any other act required by this
Agreement is unintentional and caused by misunderstanding or oversight, the
Company and the Reinsurer will adjust the

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situation to what it would have been had the misunderstanding or oversight not
occurred. The party first discovering such misunderstanding or oversight, or an
act resulting from such misunderstanding or oversight, will notify the other
party in writing promptly upon discovery thereof, and the parties shall act to
correct such misunderstanding or oversight within twenty (20) Business Days of
such other party's receipt of such notice. However, this Section shall not be
construed as a waiver by either party of its right to enforce strictly the terms
of this Agreement.

3.4. Reinstatements. If a Reinsured Policy that was reduced,
terminated, or lapsed subsequent to the Inception Date is reinstated while this
Agreement is in force, the reinsurance for such Reinsured Policy shall be
reinstated automatically to the amount that would be in force if the Reinsured
Policy had not been reduced, terminated, or lapsed. The Company will pay to the
Reinsurer the Reinsurer's proportionate share of all amounts received or charged
by the Company in connection with the reinstatement.

3.5. Setoff. Any debts or credits, matured or unmatured,
liquidated or unliquidated, regardless of when they arose or were incurred, in
favor of or against either the Company or the Reinsurer with respect to this
Agreement or any other agreement between the Company and the Reinsurer, are
deemed mutual debts or credits, as the case may be, and shall be set off, and
only the net balance shall be allowed or paid.

3.6. Payments. All payments made pursuant to this Agreement
shall be made in immediately available funds. Any late payments by either party
shall accrue interest at a rate equal to the greater of 1% per month, compounded
semi-annually, or the yield on the one-year

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United States Treasury Xxxx existent on the January 1 prior to the late payment
plus 250 basis points.

3.7. Tax Treatment. If the Reinsured Policies include for U.S.
federal income tax purposes "Specified Insurance Contracts" pursuant to Section
848 of the Code, the parties agree, with respect to this Agreement, to make the
election provided in Section 1.848-2(g)(8) of the regulations issued under
Section 848. The specifics of this election are set forth on Schedule A hereto.

ARTICLE IV

REINSURANCE PREMIUM

4.1. Initial Reinsurance Premium. On the Inception Date, the
Company shall pay to the Reinsurer an amount (the "Initial Reinsurance Premium")
equal to the Unearned Premium Reserve as of the Inception Date.

4.2. Policy Premiums. In addition to the Initial Reinsurance
Premium, the Company shall pay to the Reinsurer an amount equal to the Net
Premiums recorded by the Company on its books and records in accordance with SAP
in connection with the Reinsured Policies from and after the Inception Date (the
"Policy Premiums"). "Net Premiums" shall mean (i) gross premiums with respect to
the Reinsured Policies less (ii) return premiums with respect to cancellations
of Reinsured Policies. Net Premiums may, in any Accounting Period, be a positive
or a negative amount.

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ARTICLE V

RESERVES

5.1. Reserves and Reserve Credits. The Reinsurer shall
establish and maintain adequate reserves with respect to the Reinsured Policies
as are necessary to enable the Company to take full credit for the reinsurance
provided by this Agreement on its statutory balance sheet filed with the
insurance departments of all states in which the Company files its annual
statement, including, but not limited to, establishing and maintaining reserves
to enable the Company to comply with ss. 125.5(b) of the New York Insurance
Regulations.

ARTICLE VI

EXPENSE ALLOWANCES

6.1. Initial Expense Allowance and Quarterly Expense
Allowances. On the Inception Date, the Reinsurer shall pay to the Company an
initial expense allowance (the "Initial Expense Allowance") equal to an amount
to be determined by the Company and the Reinsurer prior to June 30, 1999 and
documented by an endorsement to this Agreement. The Reinsurer shall pay to the
Company additional expense allowances with respect to each Accounting Period
commencing on or after the Inception Date (the "Quarterly Expense Allowances")
equal to an amount to be determined by the Company and the Reinsurer prior to
June 30, 1999 and documented by an endorsement to this Agreement.

6.2. Determination of Expense Allowances. The Initial and
Quarterly Expense Allowances shall be determined by the Company and the
Reinsurer to be an amount to reimburse the Company for premium taxes,
commissions, guaranty fund assessments and other

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underwriting expenses allocated directly or indirectly to the Reinsured Risks,
plus such additional amounts as are customary with respect to coinsurance of the
type provided for in this Agreement. In the event that the Company and the
Reinsurer are unable to agree upon the Initial Expense Allowance or the
Quarterly Expense Allowance prior to July 1, 1999, such amounts shall be
determined by arbitration pursuant to Article XI hereof.

ARTICLE VII

ACCOUNTING AND SETTLEMENT

7.1. Amounts Due the Reinsurer or the Company. Except as
otherwise specifically provided herein, all amounts due to be paid to either the
Reinsurer or the Company under this Agreement shall be determined on a net
basis, giving full effect to Section 3.5 hereof, as of the last day of each
Accounting Period, and each such net amount (the "Quarterly Settlement") that
results in an amount due the Reinsurer shall be paid by the Company to the
Reinsurer in accordance with Section 3.6 concurrent with the delivery of the
Quarterly Report for such Accounting Period, and each Quarterly Settlement that
results in an amount due the Company shall be paid by the Reinsurer to the
Company in accordance with Section 3.6 no later than thirty (30) days after
delivery of such Quarterly Report, as applicable. All amounts due as of the
Inception Date also shall be determined and paid on a net basis.

7.2. Initial Report. A report shall be provided by the Company
to the Reinsurer on the Inception Date providing the data required in Schedule B
- Part I (the "Initial Report").

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7.3. Quarterly Reports. Within thirty (30) days of the end of
each Accounting Period, the Company shall supply the Reinsurer with a report
that shall provide the financial data for such Accounting Period required in
Schedule B - Part II (the "Quarterly Report").

7.4. Annual Reports. Within forty-five (45) days after the end
of each calendar year, the Company shall supply the Reinsurer with a report that
shall provide the Reinsured Policy data for such year required in Schedule B -
Part II (the "Annual Report").

7.5. Best Efforts to Supply Actual Data. In preparing all
reports required in this Agreement, including, without limitation, the Initial
Report, the Company shall use its best efforts to supply the actual data. If the
actual data cannot be supplied with the appropriate report, the Company shall
produce best estimates and shall provide amended reports based on actual data no
more than ten (10) Business Days after the actual data becomes available.

7.6. Additional Reports and Updates. For so long as this
Agreement remains in effect, the Company shall periodically furnish to the
Reinsurer such other reports and information as may be reasonably required by
the Reinsurer and reasonably available to the Company.

ARTICLE VIII

DURATION AND TERMINATION

8.1. Duration. Except as otherwise provided herein, this
Agreement shall be unlimited in duration.

8.2. Reinsurer's Liability. The Reinsurer's liability with
respect to the Reinsured Risks will terminate on the earlier of: (i) the date
the Company's liability with respect to the

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Reinsured Risks are terminated or (ii) the date this Agreement is terminated by
mutual agreement of the parties.

ARTICLE IX

INSOLVENCY

9.1. Payments. In the event of the insolvency of the Company,
net payments due the Company on all reinsurance made, ceded, renewed or
otherwise becoming effective under this Agreement shall be payable by the
Reinsurer directly to the Company or to its liquidator, receiver, or statutory
successor on the basis of the liability of the Company under the policy or
policies reinsured, without diminution because of the insolvency of the Company.
It is agreed and understood, however, (i) that in the event of the insolvency of
the Company, the Reinsurer shall be given written notice of the pendency of a
claim against the insolvent Company on a Reinsured Policy within a reasonable
time after such claim is filed in the insolvency proceeding and (ii) that during
the pendency of such claim the Reinsurer may investigate such claim and
interpose, at its own expense, in the proceeding where such claim is to be
adjudicated any defenses which it may deem available to the Company or its
liquidator, receiver or statutory successor.

9.2. Expenses. It is further understood that any expense thus
incurred by the Reinsurer pursuant to Section 9.1 shall be chargeable, subject
to court approval, against the insolvent Company as part of the expense of
liquidation to the extent of a proportionate share of the benefit which may
accrue to the Company solely as a result of the defense undertaken by the
Reinsurer. Where two or more assuming reinsurers are involved in the same claim
and a

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majority in interest elect to interpose defenses to such claim, the expense
shall be apportioned in accordance with the terms of this Agreement as though
such expense had been incurred by the Company.

ARTICLE X

WITHHELD FUNDS

The Reinsurer agrees that the Company shall have the right to
withhold from payment to the Reinsurer, as security for the fulfillment by the
Reinsurer of its obligations under this Agreement, amounts otherwise payable to
the Reinsurer hereunder, not to exceed the Total Ceded Reserves from time to
time (the "Withheld Funds"). The Company shall credit to the Withheld Funds an
investment return with respect to such assets in accordance with the following
formula (references therein being to the Annual Statement Blank):

Rate = 2(I+CG)
--------------
X + Y - I - CG

Where: I is the net investment income (Exhibit 2,
Line 16, Column 7)

CG is capital gains less capital losses
(Exhibit 4, Line 10, Column 6)

X is the current year cash and invested assets
(Page 2, Line 10A, Column 1) plus investment
income due and accrued (Page 2, Line 16,
Column 1) less borrowed money (Page 3, Line
22, Column 1)

Y is the same as X but for the prior year.

The amount of the Withheld Funds shall be adjusted by the parties on a quarterly
basis as set forth in Section 7.3 hereof.

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ARTICLE XI

ARBITRATION

Any dispute arising out of or relating to the interpretation,
performance or breach of this Agreement, including the formation or validity
thereof, shall be submitted for decision to a panel of three arbitrators. Notice
requesting arbitration must be in writing and sent certified or registered mail,
return receipt requested.

One arbitrator shall be chosen by each party and the two
arbitrators shall, before instituting the hearing, choose an impartial third
arbitrator (the "Umpire") who shall preside at the hearing. If either party
fails to appoint its arbitrator within 30 days after being requested to do so by
the other party, the latter, after 10 days notice by certified or registered
mail of its intention to do so, may appoint the second arbitrator.

If the two arbitrators are unable to agree upon the selection
of the Umpire within 30 days of their appointment, then each arbitrator shall
submit to the other a list of three Umpire candidates. Each arbitrator shall
strike the names of two candidates from the other arbitrator's list, and the
Umpire shall be selected from the two remaining candidates by a lot drawing
procedure determined by the two arbitrators.

Unless the parties otherwise agree all arbitrators shall be
disinterested active or former officers of insurance or reinsurance companies.

Within 30 days after notice of appointment of all arbitrators,
the panel shall meet and determine a schedule for the conduct of the
arbitration, including hearings. The panel shall be relieved of all judicial
formality and shall not be bound by the strict rules of procedure and evidence.
The panel shall determine where the arbitration shall take place.

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To the extent and only to the extent that the provisions of this Agreement are
ambiguous or unclear, the panel shall make its decision considering the custom
and practice of the applicable insurance and reinsurance business. Insofar as
the arbitration panel looks to substantive law, the law of Iowa shall govern.
The decision of any two arbitrators when rendered in writing shall be final and
binding. The panel is empowered to grant interim relief as it may deem
appropriate.

The panel shall render its decision, which shall be in writing
and state the reasons therefor, within 60 days following the termination of
hearings. Judgment upon the award may be entered in any court having
jurisdiction thereof. Each party shall bear the expense of its own arbitrator
and shall jointly and equally bear with the other party the cost of the Umpire.
The remaining costs of the arbitration shall be allocated by the panel. The
panel may, at its discretion, award such further costs and expenses as it
considers appropriate, including but not limited to interest (determined at the
Panel's discretion) and attorneys' fees, to the extent permitted by law.

ARTICLE XII

MISCELLANEOUS PROVISIONS

12.1. Headings and Schedules. Headings used herein are not a
part of this Agreement and shall not affect the terms hereof. The attached
Schedules are a part of this Agreement.

12.2. Notices. All notices and communications hereunder shall
be in writing and shall become effective when received. Any written notice shall
be by either certified or

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registered mail, return receipt requested, or overnight delivery service
(providing for delivery receipt) or delivered by hand. All notices or
communications under this Agreement shall be addressed as follows:

If to the Company:

Principal Mutual Life Insurance Company
Xxxx Xxxxx
Principal Mutual Life Insurance Company
000 Xxxx Xxxxxx
Xxx Xxxxxx, Xxxx 00000
Telecopy Number: (000) 000-0000

with a copy to:

Xxxxxx X. Xxxxx, Esq.
Xxxxxxx, Xxxxxx & Green, P.C.
0000 00xx Xxxxxx, X.X., Xxxxx 000
Xxxxxxxxxx, X.X. 00000
Telecopy Number: (000) 000-0000

and

Xxxxx X. Xxxxx, Esq.
Principal Mutual Life Insurance Company
000 Xxxx Xxxxxx
Xxx Xxxxxx, Xxxx 00000
Telecopy Number: (000) 000-0000

If to the Reinsurer:

Coventry Health and Life Insurance Company
[ ]
[ ]
[ ]
Attention: President

12.3. Successors and Assigns. This Agreement shall be binding
upon and inure to the benefit of the parties hereto and their respective
successors, assigns and legal

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representatives. Neither this Agreement, nor any right hereunder, may be
assigned by any party without the prior written consent of the other party.

12.4. Execution in Counterpart. This Agreement may be
executed by the parties hereto in any number of counterparts, and by each of the
parties hereto in separate counterparts, each of which counterparts, when so
executed and delivered, shall be deemed to be an original, but all such
counterparts shall together constitute but one and the same instrument.

12.5. Currency. Whenever the word "Dollars" or the "$" sign
appear in this Agreement, they shall be construed to mean United States Dollars,
and all transactions under this Agreement shall be in United States Dollars.

12.6. Amendments. This Agreement may not be changed, altered
or modified unless the same shall be in writing executed by the Company and the
Reinsurer.

12.7. Governing Law. This Agreement shall be interpreted and
governed by the laws of the State of Iowa without regard to its rules with
respect to conflicts of law.

12.8. Integration. This Agreement and the Merger Agreement
constitute the entire agreement between the parties hereto relating to the
subject matter hereof and supersedes all prior and contemporaneous agreements,
understandings, negotiations and discussions, whether oral or written, of the
parties and there are no general or specific warranties, representations or
other agreements by or among the parties in connection with the entering into of
this Agreement or the subject matter hereof except as specifically set forth or
contemplated herein.

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12.9. No Waiver. No consent or waiver, express or implied, by
any party to or of any breach or default by any other party in the performance
by such other party of its obligations hereunder shall be deemed or construed to
be a consent or waiver to or of any other breach or default in the performance
of obligations hereunder by such other party hereunder. Failure on the part of
any party to complain of any act or failure to act of any other party or to
declare any other party in default, irrespective of how long such failure
continues, shall not constitute a waiver by such first party of any of its
rights hereunder.

IN WITNESS WHEREOF, the parties hereto have caused this
Agreement to be executed by their duly authorized representatives.

PRINCIPAL MUTUAL LIFE INSURANCE COMPANY

By
----------------------------------------------
Name:
Title:

COVENTRY HEALTH AND LIFE INSURANCE COMPANY

By
----------------------------------------------
Name:
Title:

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SCHEDULE A

TAX ELECTION

The Company and the Reinsurer agree to the following pursuant to Section
1.848-2(g)(8) of the Income Tax Regulations issued under Section 848 of the Code
(hereinafter "Section 1.848- 2(g)(8)").

1. As used below, the phrases "net positive consideration,"
"capitalize specified policy acquisition expenses," "general
deductions limitation" and "net consideration" shall have the
meaning used in Section 1.848-2(g)(8).

2. The party with net positive consideration for this Agreement
for any taxable year beginning with the taxable year
prescribed in paragraph 4 below will capitalize specified
policy acquisition expenses with respect to this Agreement
without regard to the general deductions limitation.

3. The parties agree to exchange information pertaining to the
amount of net consideration under this Agreement to ensure
consistency. This will be accomplished as follows:

(a) The Company shall submit to the Reinsurer by the
fifteenth day of May in each year its calculation of
the net consideration for the preceding calendar
year. Such calculation will be accompanied by a
statement signed by an officer of the Company stating
that the Company will report such net consideration
in its tax return for the preceding calendar year.

(b) The Reinsurer may contest such calculation by
providing an alternative calculation to the Company
in writing within 30 days after the Reinsurer's

receipt of the Company's calculation. If the
Reinsurer does not so notify the Company, the
Reinsurer will report the net consideration as
determined by the Company in the Reinsurer's tax
return for the previous calendar year.

(c) If the Reinsurer contests the Company's calculation
of the net consideration, the parties will act in
good faith to reach an agreement as to the correct
amount within 30 days after the date the Reinsurer
submits its alternative calculation. Each party shall
report such amount in their respective tax returns
for the preceding calendar year.

4. This election shall be effective for 1998 and all subsequent
taxable years for which the Agreement remains in effect.

SCHEDULE B - PART I

INITIAL REINSURANCE REPORT

1. Initial Reinsurance Premium $___________

2. Initial Expense Allowance $___________

3. Net Due Reinsurer $___________

SCHEDULE B - PART II

REINSURANCE REPORTS

1. Policy Premiums

(a) Gross Premiums $___________
(b) Return Premiums (_________)
(c) Net Premiums $__________

2. Quarterly Expense Allowance $__________

3. Reinsurance Benefits

(a) Ultimate Net Loss $___________
(b) Unearned Premium Payments ___________
(c) Total $__________

4. Withheld Funds Adjustment

(a) Total Ceded Reserves $___________
(b) Withheld Funds $___________
(c) Net $__________

4. Quarterly Settlement Amount $__________

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