Indiana Code Title 27. Insurance § 27-8-3-12

(1) First, what number of certificates or policies were issued during the year or applicants admitted?

(2) Second, what was the amount of death indemnity affected thereby?

(3) Third, what number of death losses were incurred?

(4) Fourth, what number of death losses were paid and amount thereof?

(5) Fifth, what were the total number of indemnity claims paid and amount thereof?

(6) Sixth, what were the number of death and number of indemnity claims unpaid?

(7) Seventh, does the corporation, association, or society charge annual dues or membership fee?  If so, how much?

(8) Eighth, what was the total amount received and whether from assessment, annual dues, membership fees, or other sources, and the disposition thereof?

(9) Ninth, does corporation, association, or society use moneys received for payment of claims to pay expenses, in whole or in part?  And, if so, state the amount used.

(10) Tenth, what is the amount of the emergency fund and how invested?

(11) Eleventh, if organized under the laws of this state, state such fact and the date of organization.

(12) Twelfth, what were the number of policies in force and death insurance in force at the beginning of the year, and such other information as may be required by the superintendent of insurance?