**Carrier Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Code \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**FEHBP BALANCE SHEET**

**SEPTEMBER 30, 2001 AND 2000**

**[2001]{.underline}** **[2000]{.underline}**

**ASSETS**

Cash and Cash Equivalents \$ \$

####  

Balance in Letter of Credit (LOC) Account

Interest Income Receivable

Program Income Receivable

Prepaid Expenses

Other Assets

**TOTAL ASSETS \$ \$**

**LIABILITIES**

Health Benefits Accrued but Unpaid \$ \$

Accrued Administrative Expenses and Retentions

Other Accrued Liabilities

Special Reserve

**TOTAL LIABILITIES WITH SPECIAL RESERVE \$ \$**

**See accompanying notes to financial statements.**

**Instructions for Preparing**

**[The FEHBP BALANCE SHEET]{.underline}**

If your plan has an underwriter, please provide a consolidated balance
sheet incorporating the financial activity of the underwriter,
organization and former underwriter(s), if applicable. Please provide
separate balance sheets for each entity if they are available.

In addition, if your Plan has high and standard options, please provide
a balance sheet for each option.

# ASSETS

**[Cash and Cash Equivalents.]{.underline}** The ending cash and cash
equivalents balance as shown on the Consolidated Statement of FEHBP Cash
Flows and other related schedules.

**[Balance in Letter of Credit Account.]{.underline}** The balance in
the LOC account as of September 30, 2001. This should agree with line 4e
of Enclosure A.

**[Interest Income Receivable.]{.underline}** All accrued interest
income from bank accounts or short-term investments maintained for
payment of FEHBP expenses as of September 30, 2001. [Do not]{.underline}
include accrued interest from the Letter of Credit (LOC) account.

**[Program Income Receivable.]{.underline}** The ending accrued
semimonthly premiums from line 1c(1) and ending accrued LOC account
interest from line 1c(2) the Summary Statement. These calculations are
provided on your Enclosure A.

**[Prepaid Expenses.]{.underline}** The prepaid expenses as of September
30, 2001.

# 

# LIABILITIES

**[Health Benefits Accrued but Unpaid.]{.underline}** The ending health
benefits charges accrued but unpaid from line 2b(2) of the Summary
Statement.

**[Accrued Administrative Expenses and Retentions.]{.underline}** The
total accrued administrative expenses and retentions as of September 30,
2001 from line 3b(2) of the Summary Statement.

**[Special Reserve.]{.underline}** The ending Special Reserve from line
5g of the Summary Statement.

**Note: The Balance Sheet should be prepared in accordance with the
special purpose financial statements required by the U.S. Office of
Personnel Management. This is a comprehensive basis of accounting other
than generally accepted accounting principles.**

**Carrier:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Code:\_\_\_\_\_\_\_\_\_**

**STATEMENT OF OPERATIONS**

**FOR THE FISCAL YEARS**

##  ENDING SEPTEMBER 30, 2001 and 2000

**[2001]{.underline}** **[2000]{.underline}**

**REVENUE**

Letter of Credit (LOC) Authorizations \$ \$

Net Investment Income

Total Revenue \$ \$

**BENEFITS AND EXPENSES**

Health Benefit Charges \$ \$

Administrative Expenses

State Statutory Reserve

Reinsurance Expenses

Service Charges

Other

Total Benefits and Expenses \$ \$

**GAIN (LOSS) FROM OPERATIONS \$ \$**

Special Reserve, Beginning of Year \$ \$

Gain (Loss) from Operations

Return of Excess Reserves

Contingency Reserve Payments

Other

Special Reserve, End of Year \$ \$

***See accompanying notes to financial statements.***

**Instructions for Preparing**

**[The FEHBP STATEMENT OF OPERATIONS]{.underline}**

Enclosure A of the covering letter shows the Letter of Credit (LOC)
authorizations and reductions recorded by OPM for your plan during
fiscal year 2001. This information [must]{.underline} be used to prepare
your report. Please compare this information and your records and notify
Zaff Shafi of the Benefits Accounting Branch on (202) 606-4189 of any
differences. As noted previously, the amount reported as LOC drawdowns
must be the total amount requested from OPM and not the net amount
received pursuant to the provisions of the Debt Collection Act of 1996.

**[REVENUE:]{.underline}**

> **[Letter of Credit Authorizations:]{.underline}** Show the total 2001
> fiscal year semi-monthly premium authorizations as stated on Enclosure
> A.
>
> **[Net Investment Income:]{.underline}** Show the 2001 fiscal year
> interest credited to the LOC account as stated on Enclosure A plus
> investment interest earned on funds held by the carrier, if
> applicable.

**[Total Revenue:]{.underline}** Letter of Credit Authorizations plus
Net Investment Income.

[**BENEFITS AND EXPENSES:**]{.underline}

**[Health Benefits Charges:]{.underline}** Show the amount paid for
health benefit charges during fiscal year 2001.

**[Administrative Expenses]{.underline}**: Your contract with OPM
provides for allowable charges to the Federal Employees Health Benefits
Program based on an administrative expense formula for contract year
2001. The amount stated for fiscal year 2001 should not exceed 25% of
your 2000 limitation plus 75% of your 2001 limitation.

> [**State Statutory Reserve**:]{.underline} Report the amount necessary
> to satisfy State requirements for mandatory statutory reserves. Attach
> a schedule showing in detail the calculation of the required reserve
> amount and citation to specific state statues.
>
> [**Reinsurance Expenses:**]{.underline} Report the amount of
> reinsurance expenses, if applicable, incurred in fiscal year 2001.
> Attach a schedule showing the development of your reinsurance expenses
> and the basis for this charge.

**Instructions for Preparing**

**[The FEHBP STATEMENT OF OPERATIONS]{.underline}** continued:

> **[Service Charges:]{.underline}** This amount should not exceed 25%
> of your allowable 2000 service charge plus 75% of the 2001 allowable
> service charge as stated on Appendix B of the 2001 contract amendment.

**[Other:]{.underline}** Show all other expenses not previously listed.

**[Total Benefits and Expenses]{.underline}**: Sum of benefits and
expenses.

**GAIN (LOSS) FROM OPERATIONS:**

> **[Special Reserve Beginning of Year:]{.underline}** Show the ending
> special reserve from the prior year's fiscal accounting statement.

**[Gain (Loss) from Operations:]{.underline}** Total revenue minus total
benefits and expenses.

> **[Return of Excess Reserves]{.underline}**: Show the amount of excess
> reserves withdrawn from your LOC account and transferred to the
> contingency reserve during fiscal year 2001 shown on Enclosure A.
>
> **[Contingency Reserve Transfers:]{.underline}** Show the contingency
> reserve transfer(s) authorized to the LOC account during fiscal year
> 2001 as shown on Enclosure A.
>
> **[Other]{.underline}**: Show all other additions or subtractions not
> classified. Include a supporting schedule to explain the source of the
> adjustment(s).
>
> **[Special Reserve at End of Year]{.underline}**: The beginning
> Special Reserve plus or minus adjustments made during fiscal year
> 2001.

Carrier:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Code:\_\_\_\_\_\_\_\_

**STATEMENT OF CASH FLOWS**

**FOR THE FISCAL YEARS**

**ENDING SEPTEMBER 30, 2001 AND 2000**

**[2001]{.underline} [2000]{.underline}**

**CASH FLOWS FROM OPERATING ACTIVITIES**

Net Gain (Loss) \$ \$

Adjustments to Reconcile Net Gain to Net Cash

Provided by (used in) Operating Activities:

(Increase) Decrease in Assets: \$ \$

Letter of Credit Account

Program Income Receivable

Interest Income Receivable

Prepaid Expenses

Other Assets

Increase (Decrease) in Liabilities: \$ \$

Health Benefits Charges Accrued but Unpaid

Accrued Administrative Expenses

Accrued Service Charge

Other Accrued Liabilities

**TOTAL ADJUSTMENTS \$ \$**

Net cash provided by operating activities \$ \$

**(Continued Next Page)**

**[The FEHBP STATEMENT OF CASH FLOWS]{.underline}** (Continued from
previous page)

**CASH FLOWS FROM INVESTMENT ACTIVITIES**

Proceeds from Sale of Investments \$ \$

Net Cash Provided by Investing Activities \$ \$

**NET INCREASE IN CASH AND CASH EQUIVALENTS**

Cash and Cash Equivalents at the Beginning of Year \$ \$

Cash and Cash Equivalents at the End of Year \$ \$

***See accompanying notes to financial statements.***

**Instructions for Preparing**

**[The FEHBP STATEMENT OF CASH FLOWS]{.underline}**

**[CASH FLOWS FROM OPERATING ACTIVITIES]{.underline}**

**[Net Gain (Loss):]{.underline}** Show the net gain or (loss) from the
Statement of Operations.

**[Adjustments to Reconcile Net Gain (Loss) to Net Cash
Provided]{.underline}**

**[by (used in) Operating Activities:]{.underline}**

> Prior Period adjustments and other adjustments as shown on the
>
> Statement of Operations

Contingency Reserve Payments

(Withdrawal of Excess Reserves)

**[(Increase) Decrease in Assets]{.underline}:**

####  Letter of Credit Account 

####  Program Income Receivable

Interest Income Receivable

Prepaid Expenses

Other Assets

**[Increase (Decrease) in Liabilities:]{.underline}**

Health Benefits Charges Accrued but Unpaid

Accrued Administrative Expenses

Accrued Service Charge

Other Accrued Liabilities

**[Total Adjustments:]{.underline}**

**[Net Cash Provided by Operating Activities:]{.underline}**

The total net gain or (loss) plus total adjustments

**Instructions for Preparing**

**[The FEHBP STATEMENT OF CASH FLOWS]{.underline}** continued

**[CASH FLOWS FROM INVESTMENT ACTIVITIES:]{.underline}**

**[Proceeds from Sale of Investments:]{.underline}** Present the sum of
proceeds received from the sale of FEHBP investments.

**[Net Cash Provided by Investing Activities:]{.underline}** Proceeds
from the sale of investments plus non-LOC interest income minus payments
for purchase of investments.

**[NET INCREASE IN CASH AND CASH EQUIVALENTS:]{.underline}** Net Cash
Provided by Operating Activities plus or minus Net Cash Provided by
Investing Activities.

**[Cash and Cash Equivalents at Beginning of Year:]{.underline}** From
the 2000 FEHBP Balance Sheet.

**[Cash and Cash Equivalents at End of Year:]{.underline}** From the
2001 Balance Sheet

Carrier:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Code:\_\_\_\_

**SUPPLEMENTAL SCHEDULE OF ADMINISTRATIVE EXPENSES**

**FOR THE FISCAL YEARS ENDED SEPTEMBER 30, 2001 AND 2000**

**[2001]{.underline} [2000]{.underline}**

# ADMINISTRATIVE EXPENSES

Rent \$ \$

Salaries

Employee Benefits

Furniture and Equipment

Maintenance

Equipment Rental

#####  Printing, Stationery and Supplies

Travel

Postage

Telephone & Telegraph

Private Wire System

Auditing Services

Legal Services

Consulting & Professional

Payroll Taxes

Utilities

Insurance

LOC Bank Charges

Cost Containment

Other

**TOTAL \$ \$**

***See accompanying independent auditors' report.***

**DOD PROJECT**

#### Carrier:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Code:\_\_\_\_

**SUPPLEMENTAL SCHEDULE OF ADMINISTRATIVE EXPENSES**

**FOR THE FISCAL YEARS ENDED SEPTEMBER 30, 2001 AND 2000**

# ADMINISTRATIVE EXPENSES [2001]{.underline} [2000]{.underline}

Rent \$ \$

Salaries

Employee Benefits

Furniture and Equipment

Maintenance

Equipment Rental

#####  Printing, Stationery and Supplies

Travel

Postage

Telephone & Telegraph

Private Wire System

Auditing Service

Legal Services

Consulting & Professional

Payroll Taxes

Utilities

Insurance

LOC Bank Charges

Cost Containment

Other

**TOTAL \$ \$**

***See accompanying independent auditors' report.***

**Instructions for Preparing**

**The FEHBP SUPPLEMENTAL SCHEDULE OF ADMINISTRATIVE EXPENSES**

> Show your Plan's total expenses, by object class. The total charged
> should be shown on the Statement of Operations and must not exceed the
> 2001 fiscal year administrative expenses limitation.
>
> Attach a supporting showing the basis and statistical data used for
> prorating administrative expenses between options, e.g. number of
> claims paid, or other units of work performed.
>
> If the line item "Other" expenses aggregates to an amount that is
> material, its composition must be disclosed in a footnote.
>
> A separate administrative expense schedule should be prepared for
> expenses pertaining to the \"DOD Project\" for the fiscal year ended
> September 30, 2001. This should be the amount listed in Section 3 in
> the DOD column of your Summary Statement.

Carrier:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Code:\_\_\_\_\_\_

**High Option \_\_\_\_\_\_ Standard Option**\_\_\_\_\_\_\_
**DOD**\_\_\_\_\_\_\_

**SUPPLEMENTAL SCHEDULE OF HEALTH BENEFIT CHARGES PAID**

**FOR THE FISCAL YEAR ENDED SEPTEMBER 30, 2001**

**PART A - Monthly Claims Paid**

+-----------------+--------+-----------+---------------+-------------+
|                 |        | ### YEAR  |               |             |
|                 |        |  INCURRED |               |             |
+-----------------+--------+-----------+---------------+-------------+
| ### MONTH       | **AM   | **1       | **10/01/99**  | **FISCAL    |
|                 | OUNT** | 0/01/00** |               | YEAR**      |
|                 |        |           | **09/30/00**  |             |
|                 | **     | **0       |               | **1999 --   |
|                 | PAID** | 9/30/01** |               | PRIOR**     |
+-----------------+--------+-----------+---------------+-------------+

+-----------------+--------+-----------+---------------+-------------+
| October         | \$     | \$        | \$            | \$          |
|                 |        |           |               |             |
| November        |        |           |               |             |
|                 |        |           |               |             |
| December        |        |           |               |             |
|                 |        |           |               |             |
| January         |        |           |               |             |
|                 |        |           |               |             |
| February        |        |           |               |             |
|                 |        |           |               |             |
| March           |        |           |               |             |
|                 |        |           |               |             |
| April           |        |           |               |             |
|                 |        |           |               |             |
| May             |        |           |               |             |
|                 |        |           |               |             |
| June            |        |           |               |             |
|                 |        |           |               |             |
| July            |        |           |               |             |
|                 |        |           |               |             |
| August          |        |           |               |             |
|                 |        |           |               |             |
| September       |        |           |               |             |
|                 |        |           |               |             |
| Total           |        |           |               |             |
+-----------------+--------+-----------+---------------+-------------+

**PART B - Number of Claims Paid**

  ----------------- ----------------- ----------------- -----------------
                    FISCAL YEAR                         
                    INCURRED                            

                    FISCAL 2001       FISCAL 2000       1999 - PRIOR

  TOTAL                                                 
  ----------------- ----------------- ----------------- -----------------

**(Continued Next Page)**

**SUPPLEMENTAL SCHEDULE OF HEALTH BENEFIT CHARGES PAID FOR**

**THE FISCAL YEAR ENDED SEPTEMBER 30, 2001** (Continued from previous
page)

## PART C - Types of Claim Paid

  ----------------- --------------------- ---------------- -----------------
  **TOTAL**         **HOSPITALIZATION**   **PHYSICIANS**   **OTHER**

  ----------------- --------------------- ---------------- -----------------

**PART D - Reconciliation of Health Benefit Charges Paid**

Total Claims Paid from Part A *(above) -*

Less: Reinsurance Recovery

Other Adjustments *(explain)*

TOTAL (Summary Statement) \$

***See accompanying independent auditors' report.***

Carrier:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Code:\_\_\_\_\_\_

**DOD**\_\_\_\_\_\_\_

**SUPPLEMENTAL SCHEDULE OF HEALTH BENEFIT CHARGES PAID**

**FOR THE FISCAL YEAR ENDED SEPTEMBER 30, 2001**

**PART A - Monthly Claims Paid**

+-----------------+--------+-----------+---------------+-------------+
|                 |        | ### YEAR  |               |             |
|                 |        |  INCURRED |               |             |
+-----------------+--------+-----------+---------------+-------------+
| ###  MONTH      | **     | **1       | **10/01/99**  | **FISCAL    |
|                 | AMOUNT | 0/01/00** |               | YEAR**      |
|                 | PAID** |           | **09/30/00**  |             |
|                 |        | **0       |               | **1999 --   |
|                 |        | 9/30/01** |               | PRIOR**     |
+-----------------+--------+-----------+---------------+-------------+

+-----------------+--------+-----------+---------------+-------------+
| October         | \$     | \$        | \$            | \$          |
|                 |        |           |               |             |
| November        |        |           |               |             |
|                 |        |           |               |             |
| December        |        |           |               |             |
|                 |        |           |               |             |
| January         |        |           |               |             |
|                 |        |           |               |             |
| February        |        |           |               |             |
|                 |        |           |               |             |
| March           |        |           |               |             |
|                 |        |           |               |             |
| April           |        |           |               |             |
|                 |        |           |               |             |
| May             |        |           |               |             |
|                 |        |           |               |             |
| June            |        |           |               |             |
|                 |        |           |               |             |
| July            |        |           |               |             |
|                 |        |           |               |             |
| August          |        |           |               |             |
|                 |        |           |               |             |
| September       |        |           |               |             |
|                 |        |           |               |             |
| Total           |        |           |               |             |
+-----------------+--------+-----------+---------------+-------------+

**PART B - Number of Claims Paid**

  ----------------- ----------------- ----------------- -----------------
                    FISCAL YEAR                         
                    INCURRED                            

                    FISCAL 2001       FISCAL 2000       1999 - PRIOR

  TOTAL                                                 
  ----------------- ----------------- ----------------- -----------------

**(Continued Next Page)**

**SUPPLEMENTAL SCHEDULE OF HEALTH BENEFIT CHARGES PAID**

**FOR THE FISCAL YEAR ENDED SEPTEMBER 30, 2001** (Continued from
previous page)

## PART C - Types of Claim Paid

  ----------------- --------------------- ---------------- -----------------
  **TOTAL**         **HOSPITALIZATION**   **PHYSICIANS**   **OTHER**

                                                           
  ----------------- --------------------- ---------------- -----------------

**PART D - Reconciliation of Health Benefit Charges Paid**

Total Claims Paid from Part A *(above)*

Less: Reinsurance Recovery

Other Adjustments *(explain)*

TOTAL (Summary Statement) \$

***See accompanying independent auditors' report.***

**Instructions for Preparing**

# SUPPLEMENTAL SCHEDULE OF HEALTH BENEFITS CHARGES PAID

**[Part A: Monthly Claims Paid]{.underline}**

Report in the first column the amount of health benefits charges
[paid]{.underline} in each month. In the second, third and fourth
columns, show a breakdown of the amount reported in the first column by
the fiscal year incurred.

**[Part B: Number of Claims Paid]{.underline}** - Self-explanatory.

## Part C: Types of Claims Paid

If possible, separate claims paid into hospitalization, physicians, and
other claims.

**[Part D: Reconciliation of Health Benefit Charges Paid.]{.underline}**

Self-explanatory.

Carrier
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Code \_\_\_\_\_\_\_\_\_\_

**SUPPLEMENTAL SCHEDULE OF MONTHLY CASH FLOWS**

**FOR THE PERIOD ENDING SEPTEMBER 30, 2001**

**[SOURCES OF CASH APPLICATIONS OF CASH]{.underline}**

**(1) (2) (3) (4) (5) (6) (7) (8)**

**Cash and Cash**

**Month LOC Interest Other Claims Admin. Other Net Inflow Equivalents
[Drawdowns]{.underline} [Income]{.underline} [(explain)]{.underline}
[Paid]{.underline} [Exp.]{.underline} [(explain)]{.underline}
[(Outflow)]{.underline} [Monthly ]{.underline}**

**Balance -- 09/30/00**

**Oct. 2000**

**Nov. 2000**

**Dec. 2000**

**Jan. 2001**

**Feb. 2001**

**Mar. 2001**

**Apr. 2001**

**May. 2001**

**June 2001**

**July 2001**

**Aug. 2001**

**Sep. 2001**

**Instructions for Preparing**

**[THE FEHBP SUPPLEMENTAL SCHEDULE OF MONTHLY CASH FLOWS]{.underline}**

This schedule must be prepared on a monthly basis for the period October
1, 2000 through September 30, 2001.

-   [Cash Balance:]{.underline} The total of ending cash balance and
    total value of investments held by carrier as shown on your 2000
    fiscal year accounting statement, and as of the end of each month
    through September 30, 2001.

```{=html}
<!-- -->
```
-   [Sources of Cash:]{.underline}

1)  [LOC Drawdowns.]{.underline} Withdrawals made from your Letter of
    Credit (LOC) account as shown on line 4b. of Enclosure A.

2)  [Interest Income.]{.underline} Interest earned on funds held during
    the period October 1, 2000, through September 30, 2001, other than
    the LOC account.

3)  [Other.]{.underline} Explain via footnote or attached sheet of
    paper, all entries shown on this line.

-   [Applications of Cash:]{.underline}

4)  [Claims Paid.]{.underline} The total health benefits charges paid
    during the period October 1, 2000, through September 30, 2001.

5)  [Administrative Expenses Paid.]{.underline} The amount of cash paid
    for allowable administrative expenses during the period October 1,
    2000, through September 30, 2001.

6)  [Other.]{.underline} Explain, via footnote or attached sheet of
    paper, all entries shown on this line.

-   [Net Inflow (Outflow):]{.underline} The net of total Sources of Cash
    minus total Applications of Cash.

```{=html}
<!-- -->
```
-   [Cash and Cash Equivalents Monthly Balance:]{.underline} Previous
    month\'s balance of cash, cash equivalents, and investments plus the
    month\'s net inflow (outflow).

-   Carrier:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
    Code:\_\_\_\_\_\_

**SUPPLEMENTAL SCHEDULE OF AUDIT FINDINGS**

**FOR THE FISCAL YEAR ENDED SEPTEMBER 30, 2001**

**AUDIT NUMBER AND ASSOCIATED YEAR:**

\$ \_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_

**TOTAL** \$ \_\_\_\_\_\_\_\_\_