Transcription

----- -----.,Application Formand Supporting Documents

Uniform Certificate of Authority Application (UCAA)Primary Application Checklist· For Primary Application OnlyThe application checklist is intended to help guide you with assembling your complete Primary Uniform Certificate ofAuthority Application (UCAA). Please be sure to complete the checklist by appropriately marking the boxes on the left sideof the page prior to submitting your application for review. The completed checklist should be attached to the top of theapplication.Regulator Use Onlyro 1\ I.Application Form, containing:2./Completed Primary Application Checklist (Form I P)Original UCAA Primary Application executed and signed (Form 2P) . /Include all lines of insurance applicant is licensed to transact, currently transacting andrequesting authority to transact in all jurisdictions. (Form 3).Filing Fee (pursuant to Section II Filing Requirements Item 2) containing:[RJPayment of required fil ing fee.WL (o Copy of check( (JJ'-3. D'Jo of&--Minimum Capital and Surplus Requirements (pursuant to Section II Filing Requir ments Item 3)-t:IJI[U4.Provide explanation of compliance with minimum capital & surplus requirements for state forwhich application is preparedStatutory Deposit Requirements (pursuant to Section II Filing Requirements Item 4) An original Certificate of Deposit prepared by state of domicile (Form 7)5.DName Approval (pursuant to Section II Filing Requirements Item 5) Evidence of name approval request . -7. Holding Company Form "8" Registration Statement (pursuant to Section II FilingRequirements Item 7) Included statement ''tr'Y't-f/Uvile.1(1 . Lo,.,.{ r"1 . -D8. Statutory Membership(s)[KJDSubmit documentation as listed in Sectiqn II Filing Requirements Item 8&sWill{ fip :t--.l (OI'('i a o\- 'JoL)) fir (. S" H C?ND.itt(ll-r. [)i'tt'("(l n) '009. SEC Filings or Consolidated GAAP Financial Statement.upD Submit docu!llentation as listed in Section n F ing 5quirements It\m 9Nadaw .t.c{ed'Vu'hCa.l 10.f , 1\)"'dld-)Debt-to-Equity Ratio Statement1.D Submit documentation as listed' in Section II Fil ing Requirements hem I 0c.4S., 2008 National Association of Insurance Commissionersl1:(:i)·ms .C.OApril I, 2008

I I. Custody Agreements Submit documentation as listed in Section II Filing Requirements Item II12.DPublic Records PackageSubmit ALL items in chart in Section II Item 12 including:a.b.Articles of Incorporation, including: Original certification by domiciliary state s, c./including:Original certification by applicant's corporate assistant/Statement with Attachments, including:[RJ Current Year Annual Statement*Verified and signed,including actuarial opinion; and[KJ Current Year Quarterly Statements-one copy for each quarter, verified and signed. I. Updated Statements should be submitted on a timely basis while application is pending.2.If Annual Statement for two preceding years have not been filed with NAIC, one copy ofea.ch year must be submitted with the application.d. IJ derndent CPA-Audit ReportD13. NAIC Biographical Affidavits for the following:Officers (As listed on Jurat Page of most recent financial statement.)Directors (As listed on Jurat Page of most recent financial statement.)Key managerial personnel (Including (!ny Vice Presidents or other individuals who will controlthe operations of the applicant.) Individuals with a I 0% or more beneficial ownership in the applicant who will exercise controlover the applicant or, Officers and Directors of an entity with a 10% c:ir more beneficial ownershipin the applicant who exercise control over the applicant; and Individuals with a 10% or more beneficial ownership in the applicant's ultimate controlling personwho will exercise control over the applicant and Officers and Directors of the ultimate controllingperson who will control the operations of the applicant.[KJ Originally signed and notarized within one year of application date.Certified by Independent Third PartyLJm14. State-Specific Information Some jurisdictions may have additional requirements that must be met before a Certificate ofAuthority can be issued. Before completing a UCAA Primary Application the applicant shouldreview a listing of requirements for the state to which you are applying 2008 National Association of Insurance Commissioners2April I, 2008

Filing Requirements- Redomestications OnlyThe requirements of this section are only for those insurers seeking to redomesticate from one state to another and are inaddition to the requirements of Section II, items 1-14 of the Primary Checklist. A Redomestication is defined as the processwhere any insurer organized under the Jaws of any other state may become a domestic insurer that transfers its domicile toanother state by merger or consot"idation or any other lawful method. The Primary Application when used for a. Mredomestication is filed with the insurer's new state of domicile.15.Annual Statement with Attachments Vl\b .vrY.\h(,O V'O D S bmit documentation as listed in S.ection III, Filing Requirements Item I16. Quarterly Statements"("G n'lblrfrtl'\cP ' Submit documentation as listed in SeCtion III, Filing Require':"ents Item 217.Risk Based Capital ReportI'CKJ Submit documentation as listed in .Section III, Filing Requirements Item 318. Independent CPA Audit Report\\CKJ Submit documentation as liste in Section Ill, Filing Requirements Item 4DDDI{19. Reports of Examination Submit documentation as listed in Section Ill, Filing Requirements Item 520. Certificate of Compliance (pursuant to Section III, Filing Requirements Item 6)DF 1fl Original certification of compliance (Form 6) completed by dom.iciliary state insurance regu agency. 2008 National Association of Insurance Commissioners3April I, 2008

SY J\·David S. Goldstein· \fSenior Vice President, General Counsel and SecretarySymetra Financial Corporation777108th Avenue NE, Suite 1200Bellevue, WA 98004-5135Phon I BENEFITS I LIFEFebruary 6, 2014The Hon. Mike KreidlerInsurance CommissionerWashington State Office of the Insurance Commissioner5000 Capitol Blvd. SE,Tumwater, Washington 98501Re:Redomestication of Symetra National L[fe Insurance CompanyDear Commissioner Kreidler:With reference to our correspon ence of January 14, 2014 in which we officially requested totransfer the domicile of (or "redomesticate") Symetra life Insurance Company and Symetra National LifeInsurance Company, enclosed herewith is a .copy of the UCAA Primary Application for Redomesticationof Symetra National Life lnsur nce Co.mpany, express.mailed to the Iowa Insurance Division on February6, 2014 and which is to be filed upon receipt (the 'Application"). Except with-respect to those materialsidentified in Schedule I (attached hereto); the enclo sed ·Application identical to that which will be filedwith the Iowa ln urance Division.isWe have also enclosed an extra copy of th s letter and a return envelope. We kindly request /that you file stamp this letter and return at'your convenience. ·If you have any questions regarding this ·request, please do not hesitate to contact me.Respectfully submitted,Dt.-JI David S. GoldsteinEncl.cc:JamesT. OdiorneThomas M. MarraMargaret Meister

SCHEDULE IExhibits Excluded from the Enc,ose ApplicationThe following exhibits are excluded from the copy of the AppJication enclosed herewith, as eachof these documents is already on file with the Washington Office ofthe Insurance Commissioner: ·II-ADomestic Custody Agreement between Symetra National Life Insurance Company andJPMorgan Chase Bank, N.A.11-BGlobal Custody Rider between Symetra National Life Insurance Company and JPMorganChase Bank, N.A.15-AValuation oftbe outstanding policies of the Applicant as of December 31, 2012, andcertification of the Washington Office of the Insurance Coinmissione 17Symetra National Life Insurance Company Risk-Based Capital Report for the Year 20 12The exhibits set forth below are incorporated into the Application by reference to the UCAAExpansion Application filed on behalf of the Applicant with the Iowa Insurance Division on January 14,2014. Except as noted below, each ofthese exhibits is alre dy on file with the Washington Office oftheInsurance Commissioner, and according, has been excluded from the enclosed Application.6-BPro-Forma Financial Statement (not on tile with Washington Office of InsuranceCommissioner)'6-15Investment Manageme t Agreement with White Mountains Advisors, LLC6-22.1Services an Shared Expenses Agreement6-22.2Intercompany Short-Tenn.Borrowing Agreement6-22.3Life Company Subgroup Tax Agreement15Annual Statement of Symetra Life Insurance Company as of December 31, 201216-AQuarterly Statement ofSymetra Life Insurance Company as ofMar ;h 31, 201316-BQuarterly Statement ofSyriletra Life Insurance Company as ofJune 30,201316-CQuarterly Statement ofSymetra Life Insurance Company as of September 30,201318Audited Financial Statements ofSymetra Life Insurance Company for the Years EndedDecember 31, 2012 and 201119-A19 8·Financial Examination ofSymetra National Life Insurance Company as of December 31,2010, conducted by the State of Washington Office ofthe Insurance CommissionerMarket Conduct Examination ofSymetra Life Insurance Com pany, Symetra National LifeInsurance Conwany and American States Life Insurance Company .for the examination periodof July I; 2002- June 30,2003, conducted by the State of.Washington Office of the InsuranceCommissioner·

The exhibits set forth below are incorporated into the Application by reference t ? the UCAAPrimary Application for redomestication filed on behalf of Symetra Life Insurance Company with theIowa Insurance Division on January 14, 2014, a partial copy of which was provided to the WashingtonOffice of Insurance Commissioner on January 14, 2014. Except as noted below, each of these exhibits isalready on file with the Washington Office of the Insurance Commissioner, and according, has beenexcluded from the enclosed Appli ation.7-AAnnual Fonn B Insurance Holding Company System Registration Statement as of December31,20127-BI to. 2012 Annual Fonn B Insurance Holding Company System RegistrationAmendmentStatement as of November 13, 201310Debt-to-Equity Ratio Statement (not on file with Washington Office of InsuranceCommissioneri13NAIC Biographical Affidavits14-C.IAsset Allocation Models Service Agreement, non-disapproved by letter dated September 5,2013No.'.14-C.2Investment Management Agreement, non-disapproved by letter dated May 6, 20 II14-C.3Amendment No I. to the Investment Management Agreement, non-disapproved by letter datedFebruary 17,201214-C.414-C.S. 1,·Services and Shared Ex enses Agreement, non-disapproved by letter dated December 15,2005Amendment No. I to the Services and Shared Expenses Agreement, non-disapproved by letterdated June 22, 20 lO14-C.6Amendment No.2 to the Services and Shared Expenses Agreement, non-disapproved by letterdated February 22, 20121The pro fonna financial statements are not on file with the Washington Office of Insurance Commissioner. Thepro fonna financial statements contain infonnation that constitutes a "trade secret" u·nder applicable law, and havetherefore been exclude.d from the .copy of the Application enc.losed herewith. Trade Secrets are defined by RCW §19.108.010(4) follows: "lnfonnation, including a formu'la, pattern, co-r:npilation, program, device, method,technique, or process that: (a) Derives independent economic value, actual or potential, from not being generallyknown to, and not being readily ascertainable by proper means by, other persons who can obtain economic valuefrom its disclosure or use; and (b)' 1s the subject of efforts that are reasor:table under the circumstances to maintain itssecrecy."2The. debt to equity ratio statement is not on file with the Washington Office of Insurance Commissioner. The debt. to equity ratio statement contains information.that constitutes a ''trade secret',' under applicable law, and hastherefore been exclu4ed from the copy-ofthe Application enclosed.herewith. Trade Secrets are defined by RCW §19.108.0 I0(4) follows: "Information;· including a fonnula, pattern, compilation, program, device, method,technique, or process that: (a) Derives independent ec.onomic value, actual or potential/from not being generallyknown to, and not being readily ascertainable by proper means by, other persons who can obtain economic valuefrom its disclosure or use; and (b) Is the subject of efforts that are reasonable under the circumstances to maintain itssecrecy."2

SYMETRA NATIONAL LIFE INSURANCE COMPANY.PRIMARY APPLICATION FORREDOMESTICATION·

Applicant Name: Symetra National Life Insurance CompanyItem 1 -Application FormThe following documents are submitted as Item I of the Application:Exhibit 1-AExhibit 1-BExhibit 1-CPrimary Application Checi(list (Fonn ·I P) · ./"Original UCAA Primary Application (Fonn 2P) ./Lines of lnsuran ce (Fonn 3)/NAIC No. 90581FEnN:91-1079693

0 ::, btc fDLLV\ .5ec. s \ldl "'-- t--.t:e it(l. tillUNIFORM CERTIFICATE OF AUTHORITY APPLICATION (UCAA) ]Management Information formComplete Listing of Incorporators*, OfficersDirectors ari·d ·Shareholders (10% or more)Incorporators Ownership .Percentage:Titles:N/ASymetra National Life Insurance CompanyOfficers:PresidentMarra, Thomas M.Executive Vice President and Chief Financial OfficerMeister, Margaret A.Executive Vice PresidentFry, Michael W.Executive Vice PresidentGuilbert, Daniel R.Executive Vice PresidentLaVoice, Richard G.Senior Vice President and Chief ActuaryBrooks, Tommie D.Senior Vice President, General Counsel, and SecretaryGoldstein, DavidS.Senior Vice PresidentElder, Colin M.Senior Vice PresidentKatzmar Holmes, Christine A.Senior Vice PresidentMcKinnon, George N.Senior Vice PresidentPirak, James D.Senior Vice PresidentRaymond, Craig R.Senior Vice PresidentRoscoe, Michael J.Senior Vice PresidentSkinner, Margaret W.Senior Vice President, Controller, TreasurerMurphy, Colleen M.Vice President, Associate General Counsel, and Assistant SecretaryBodmer, Julie M.Vice President and Associate General CounselEhrenberg, MichaelanneVice President and Chief Compliance OfficerSainato, Suzanne WebbVice President, Associate GeneraLCounsel, and Assistant SecretaryVeneziani, Jacqueline M.Vice PresidentBalkovetz, ChantelVice PresidentBlack, Glenn A.Vice PresidentBouvier II, Philipp D.'Vice President,Englund, Kathryn L.Vice PresidentFarrell, Andrew M.Vice PresidentJames, Michael E.Vice PresidentMartonik, Brent P.Vice PresidentRabin, Kevin W.Vice PresidentSeverin, Wesley W. 2008 National Association of Insurance Commissioners4April I, 2008

Vice PresidentSmolinski, Richard P.Vice PresidentTakeuchi, Bridgette N.Vice PresidentThompson, Dena S.Vice PresidentValickus, JohnS.Vice PresidentWork, Mindi E.Directors:DirectorFry, Michael W.DirectorGoldstein, David S.DirectorGuilbert, Daniel R.DirectorMarra, Thomas M.DirectorMeister, Margaret A.Shareholders:100% Symetra Life Insurance Company Primary Application Only 2008 National Association of Insurance Commissioners5April I, 2008

NAIC No. 90581Applicant Name: Symetra National Life Insurance Company -------------------FErN:91-1079693Uniform Certificate of Authority ApplicatioJ:l (UCAA)Primary ApplicationTo the Insurance Commissioner/Director/Super tendent of the State oDistrict of aryland· ontanaNebraskaNevada. New HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklaho·m aOregonPennsylvaniaRhode Island· ·South niaWashingtonWest VirginiaWisconsinWyomingX-(Check the appropriate states in which you are applying.)The undersigned Insurer hereby certifies that the classes of insurance as indicated on the Lines of Insurance, Form 3, are alllines of business (a) currently authorized for transaction, (b)' currently transacted and (c) which the Insurer is apply ing totransact.·Name of Insurer: Symetra National Life Insurance Company NAIC #90581 - ·----------------'1'-'1""'2:. .9Group CodeHome Office Address: 777 I08lh Avenue. Suite 1200 Bellevue, WA 98004-5135111-- ------------------------Administrative Office Address: 777 108 Avenue. Suite 1200 Bellevue. WA 98004-Sl35----------------------Mailing Address: PO Box 34690 Seattle. WA 9 8 1 2 5 - 1 6 9 0 - - - - - - - - - - - - - - - - - - - - Phone ----Are these addresses the same as those shown on your Annual Statement?Yes[KJNoc JIf not, indicate why.102000-2008 National Association of Insurance Commissioners( rev)Scptcmbcr 7, 2006FORM2P

Applicant Name: Symetra National Life Insurance CompanyNAIC No. "'""90 5 8.:. . 1- - - - - - - FEIN:91-1079693Date Incorporated: September 4, 1979Form ofOrganization: Corporation .;.Billing Address: PO Box 34690 Seattle, WA 98124-1690E-Mail Address:Phone: ·Fax:Premium Tax Statement Address: PO Box 34690 Seattle, WA 98124-1690Phone:Fax:E-Mail Address:Producer Licensing Address: PO Box 34690 Seattle, WA 98124-1690 - - - - - - - - - - - - - - - - - - E-Mail Address:Phone:Fax:Rate/Form Filing Address: PO Box 34690 Seattle WA 98124-1690E-Mail Address:Phone:Fax: -- ----------Consumer Affairs Address: PO Box 34690 Seattle, WA 98124-1690 - - - - - - - - - - - - - - - - - - E-Mail Address: Phone: Fax:State or Country of Domicile: Washington State - - - - - - - - Date Organi:zed September 4, 1979Date of Last Amendment of Charter, Bylaws or Subscriber's Agreement: December 6. 2005 for By-Laws. July 15. 2005 for·Articles of Incorporation; SNLIC has no Charters.Date of Last Financial Examination: 12/31/ 20 I 0---------------------------Date of Last Market Conduct Examination: For the period 7/l/2002 through 6/30/2003- adopted 8/ I 2/2005Par Value of Issued Stock: 125.00 Surplus as regards policyholders: 7,217,209 as of 9/30/13Certificate of Deposit (Home State) I .524.0724 - - - - - - - - - - - - - - - - - - - - - - - - - Ultimate Owne /Holding Company: Symetra Financial Corporation indirectly owns and controls 100% of the Applicant'sissued and outstanding shares. The ultimate controlling person is White Mountains Insurance Group. Ltd., which, as ofSeptember 30. 2013. owns and controls approximately 17% of the issued and outstanding shares of Symetra FinancialCorporation.··Has your company ever been refused admission to this or any other state prior to the date of this application?Yesc JNo If Yes, give full explanation in an attached letter.The applicant hereby designates (name natural persons only) Keren Herzberg, to appoint persons and entities to act as and tobe licensed as agents·in the State oflowa, and to terminate the said. appoinunents.NOTE: This does not apply to those tatesthat do not require appointmentsThe following information is required of the individual who is authorized to represent the applicant before the department.Name David GoldsteinTitle SVP & General CounselMailing Address 777 108th Ave NE Bellevue WA 9 8 0 0 4 - - - : - - - - - - - - - - - - . , . - - - - - - - - - - E-Mail Address: [email protected] Phone: 425/256-8021 Fax: 425-256-6080 (Law Department)If the representative is not employed by the applicant, please provide a company contact person in order to facilitate requestsfor detailed financial information.Name N/A --- TitleMailing Address 2000-2008National Association of Insurance Commissioners(rev)Septcmbcr 7, 2006FORM 2P

NAIC No. 90:::.:5 8.:.1FEIN:91-1079693Applicant Name: Symetra National Life Insurance CompanyE-Mail Address: Phone: - - - - - - - - - - - F a x :Please provide a listing of all other applications filed by the applicant, or any of its affiliates, that are pending before theDepartment.The applicant's direct parent company. Svmetra Life Insurance Company, has an application to redomesticate fromWashington State to Iowa that is pending before the Iowa Insurance Division.Applicant Officers' Certification and AttestationOne of the officers (listed below) of the Applicant must read the following very carefully:1.2.3.4.I hereby certify,· under penalty of perjury, that I have read the·application, that I am familiar with its contents, andthat all of the information, including the attachments, submitted in this application is true and complete. lam awarethat submitting false infonnation or omitting pertinent or material information in connection with this application isgrounds for license discipline or other administrative action and may subject me or the Applicant, or both, to civil orcriminal penalties.·.I acknowledge that I am familiar with the insurance laws and regulations of said state, accept the Constitution ofsuch state, in which the Applicant s licensed or to which the Applicant is applying for licensure.I acknowledge that I am the Senior Vice President, General Courisel & Secretary of the Applicant, am authorized toexecute and am executing.this document on behalf of the Applicant.I hereby certify under penalty of perjury under the laws of the applicable jurisdictions that all of the forgoing is trueand correct, executed thisat Bellevue, Washington.·DateSignature of President.a' - --ra t1tt'k JFull Legal Name of PresidentDateSignature of Secretary -David Seth GoldstemFull Legal Name of SecretaryDateSignature of TreasurerFull Legal Name of TreasurerSymetra National Life lnsurance Company.App';2ant . 0 Signature of Witness .Full Legal Name of Witness 2000-2008 National Association of Insurance Commissioners(rev)September 7, 2006FORM2P

Applicant Name: Symetra National Life Insurance CompanyNAIC No. 9850 I -:-:-:-:-------FEIN:91-1079693Uniform Certificate of Authority Application (UCAA)·Expansion ApplicationLines of InsurancePlease complete the infomtation below for each state in which you are currently .lic nsed and seeking authority to dobusiness. Each state has its own tenninology for the lines of insurance. To assist in completing this fomt and in understandingthe terms used, a matrix is available that comilates each state's terms to the common terms used in the NAIC annualstatement blanks. The correlation matrix is an Excel spreadsheet and . is located on the UCAA web site athttp://www.naic'.org/documents/industry ucaa forms state lines of business matrix.xlsALABAMALife (Sec. 27-5-2)Disability (Sec. 27-5-4)Property(Sec.27-5-5)Miscellaneous·Casualty (Sec. 27-5-6,27-5-7,27-5-8, 27-5-9)Title (Sec. 27-5-1 0)ALASKAAuthorized ized d toTransactCurrentlyTransaetine:ApplyingforLife (AS 21.12.040)Health (AS 21.12.050)Disability (21.12.052)Annuities (AS 21.12.05 5)Variable Life (AS 21.42.370)Variable Annuities (AS 21.42.370)Property (AS 21.12.060)Casualty (AS 21.12.070) including clauses:(I) . Vehicle(2) Liability(3) Workers Compensation and Employers Liability(4) Burglary and Theft(5) Personal Property Floater(6) Glass(7) Boiler and Machinery·.(8) Leakage and Fire Extinguishing Equipment(9) Credit (failure of debtors to pay obligations toinsured)(10) Malpractice(II) Elevator(12) Livestock(13) Entertainments(14) M iscellan eousSurety {AS 21 . 12.080)Marine, Wet Marine & Transportation (AS 21.12.090)Mortgage Guaranty {AS 21.12.11 0)Title (AS 21 .66)Fraternal Benefit Society (AS 21.84) ,ARIZONACasualty with Workers' Compensation A.R.S. § 20-252Casualty without Workers' Compensation A.R.S. § 20-252·.Disability ARS. § 20-253 2012 National Association of Insurance CommissionersXRevised 11/26/ 12FORM3

NAICNo.98501FEIN:91-1079693------Applicant Name: Symetra National Life Insurance CompanyLife (Includes Annuities) A.R.S. § 20-254Variable Annuity A.R.S. § 20-2631 (2) ·Variable Life A.R.S. § 20 260 I (IS)Marine and Transportation A.R.S. § 20-255Mortgage Guaranty A:R.S. § 20-1541Prepaid Legal A.R.S. 20-1097Property A.R.S. § 20-256Surety A.R.S. § 20-257Title A.R.S. § 20-1562Vehicle A.R.S. § 20-259Life & Disability Reinsurer A.R.S. § 20-1082Health Care Services Or2anization A.R.S. § 20-1051Health, Medical, Dental, Optometric Service CorporationsA.R.S. § 20-824Prepaid Dental Plan Organization A.R.S. § 20-1001Applyingfor'.ARKANSASLife (ACA 23-620-102)Accident & Health (ACA 23-62-1 03)Property (ACA 23-62-1 04)Casualty (ACA 23-62-105)Surety (ACA 23-62-1 06)Workers Compensation (ACA 23-62-1 05)Marine (ACA 23-62-1 07)Title (ACA 23-62-1 08)Mortgage Guaranty (ACA 23-62-110)Authorized RNIALife (CIC 101)Fire (CIC 102)Marine (CIC I 03)Title (CIC 104)Surety (CIC 105)Disability (CIC I 06)Plate Glass (CIC I 07)Liability (CIC I08)Workers' Com pensation (CIC 109)Common Carrier Liability (CIC II 0)Boiler and Machinery (CIC Ill)Burglary (CIC 112)Credit (CIC 113jSprinkler (CIC 114)Team and Vehicle (CIC 115)Automobile (CIC 116)Mortgage (CIC 117)Aircraft (CIC 118)Mortgage Guaranty (CIC I 19)Insolvency (119.5)CurrentlyTransactingXAuthorized toTransactXARIZONA (continued)Authorized toTransactXCurrentlyTransactingXApplyingfor. 2012 National Association of Insurance CommissionersX2·'Revised 11/26/12FORM3

NAIC No. 98501FEIN:91-1079693 ,Applicant Name: Symetra National Life Insurance CompanyCALIFORNIA (continued)Authorized d toTransactCurrentlyTransactin2ApplyingforXXLegal (CIC 119.6)Miscellaneous (CJC 120)Financial Guaranty (CIC 124)COLORADOLife (10- 102(l)(b))General LifeAccident and HealthAnnuitiesCreditVariable Contracts ·Fraternal Benefit Society (10-14-603)General LifeAccident and Health\AnnuitiesVariable ContractsTitle (Title 10, Article 11) :TitleProperty and Casualty (Title 10, Article 3, Sections102(l)(a), (c) and (d) or {Title 10, Articles 12 or 13)General PropertyCropMotor VehicleGeneral CasualtyAccident and HealthFidelity and Surety (excluding bail bond)Bail BondWorkers' CompensationMortgage Guaranty'CreditProfessional Malpractice.· .-·: I.Authorized toTransactCONNECTICUT (C.G.S Title 38a)Fire, Extended Coverage and Other Allied LinesHomeowners multiple perilCommercial multiple perilEarthquakeGrowing cropsOcean marineIn land marineAccident and healthWorkers' CompensationLiability other than auto (B. I. and P.D.)Auto liability (B.I. and P.D.)Auto physical damageAircraft (all perils)Fidelity and SuretyCurrentlyTransactingApplyingforI'·-Revised 11/26112 2012 National Association of Insurance Commissioners3FORM3

Applicant Name: Symetra National Life Insurance CompanyNAIC No. 9850 I91-107--9-69 3FEIN:CONNECTICUT (C.G.S Title 38a) (continued)Financial Guaranty (mono-line)GlassBurglary and TheftBoiler and MachineryCreditReinsuranceLife Non-ParticipatingLife ParticipatingVariable Life Non-ParticipatingVariable Life ParticipatingVariable AnnuitiesTitleFraternal Benefit SocietiesHealth Care CenterCredit LifeCredit Accident and HealthMortgage Guaranty (mono-line)Residual ValueDELAWARELife [18 Del. C. Section 902] .Variable Annuities [Del. Reg 11Variable Life (Del. Reg 44]Credit Life [I 8 Del. C. Section 9021Credit Health [18 Del. C.·Seciion 903]Health [18 Del. C. Section 9031Property ( 18 Del. C. Section 904]Surety [18 Del. C. Section 905]Casualty [18 Del. C. Section 906(a)J, includingsubdivisions:(I) Vehicle(2) Liability(3) Workers' Compensation & Employer's Liability(4) Burglary & Theft(5) Personal Property Floater(6) Glass(7) Boiler & Machinery(8) Leakage & Fire Extinguisher Equipment(9) Credit(10) Malpractice(II) Elevator(12) Congenital Defects(13) Livestock(14) Entertainments( 15) MiscellaneousMarine & Transportation 118 Del. ·c. Section 9071Title [I 8 Del. C. Section 908]Authorized toTransactCurrentlyTransactin2XXXXXXXXAuthorized ngforX. .Revised lln6112 20I 2 National Association of Insurance Commissioners4FORM 3

NAIC No. 9850 I91-107-9-69 3FEIN:Applicant Name: Symetra National Life Insurance CompanyPresently, lines listed above for casualty ar checked off as individual lines on the certificate of authority application form.18 Del. C. Section 906(b)- Provision of medical, hospital, surgical and funeral benefits, and of coverage against accidentaldeath or injury, as incidental to and part of other insurance as stated under subdivisions (1) vehicle, (2) liability, (4) burglary& theft, (7) boiler & machinery, (10) malpractice and (II) elevator of subsection (a) shall for all purposes be deemed to bethe same kind of insurance to which it is so incidental and shall not be subject to provisions of this title applicable to life andhealth insurance.Authorized toTransactDISTRICT OF COLUMBIAHealth Maintenance Organizations (Sec. 31 -Chapter 34)Life and HealthIndividual LifeGroup LifeVariable Life (26 DCMR Chapter 27)Individual Accident and HealthGroup Accident and HealthIndividual Annuities (Fixed and Variable) (Sec. 31-4442)Group Annuities (Fixed and·Variable) (Sec. 31-4442)Fire and Casualty(I) Fire (Sec. 31-2502.11)(2.1) Allied Lines (Sec. 31-2502.11)(2.2) Multiple Peril Crop(2.3) Federal Flood(3) Farmowners Multiple Peril (Sec. 31-2502.11)(4) Homeowners Multiple Peril (Sec. 31-2502.11)(5.1) Commercial Multiple PeriJ.(non-liability) (Sec. 312502.11)(5.2) Commercial Multiple Peril (liabilitY) (Sec. 312502.11)(6) Mortgage.Guaranty(8) Ocean Marine (Sec. 31-2502.11)(9) Inland Marine (Sec. 31-2502.11)(10) Financial Guaranty(II) Medical Malpractice( 12) Earthquake (Sec. 31-2502.11)( 13) Group Accident & Health (Sec. 31-2502.11)( 14) Credit A&H (Group & Individual) (Sec. 31-2502.11)(15.1) Collectively Renewable A&H (Sec. 31-2502.11)(15.2) Non-cancellable A&H (Sec. 31-2502.11)(15.3) Guaranteed Renewable A&H (Sec. 31-2502, II)(

Copy of check ( (JJ'-D 3. Minimum Capital and Surplus Requirements (pursuant to Section II Filing Requir ments Item 3)-t:IJI [U Provide explanation of compliance with minimum capital & surplus requirements for state for which application is prepared 4. Statutory Deposit Require