| Annual Statement Checklist and Instructions |
ACCIDENT AND HEALTH INSURERS FILING ON THE HEALTH BLANK
| COMPANY NAME:
NAIC
Company Code:
Contact: Telephone: REQUIRED FILINGS IN THE STATE OF NEW YORK Filings Made During the Year 2012 |
(1) | (2) | (3) | (4) | (5) | (6) | (7) | ||
Domestic | Foreign | |||||||
State | NAIC | State | ||||||
I. NAIC FINANCIAL STATEMENTS | ||||||||
| 1 | Annual Statement (8 1/2" x 14") | 1 | EO | 1 | 3/1 | NAIC | ||
| 1.1 | Printed Investment Schedule detail (Pages E01-E27) | 1 | EO | 1 | 3/1 | NAIC | ||
| 2 | Quarterly Financial Statement (8 1/2" x 14") | 1 | EO | 1 | 5/15, 8/15, 11/15 | NAIC | ||
II. NAIC SUPPLEMENTS | ||||||||
| 10 | Accident & Health Policy Experience Exhibit | 1 | EO | 1 | 4/1 | NAIC | ||
| 11 | Actuarial Opinion | 1 | EO | 1 | 3/1 | Company | ||
| 12 | Health Care Exhibit (Parts 1, 2 and 3) Supplement | 1 | EO | 1 | 4/1 | NAIC | ||
| 13 | Health Care Exhibit's Allocation Report Supplement | 1 | EO | 1 | 4/1 | NAIC | ||
| 14 | Investment Risk Interrogatories | 1 | EO | 1 | 4/1 | NAIC | 15 | Life Supplemental Data due March 1 | xxx | EO | xxx | 3/1 | NAIC |
| 16 | Long Term Care Experience Reporting Forms | 1 | EO | xxx | 4/1 | NAIC | ||
| 17 | Management Discussion & Analysis | 1 | EO | 1 | 4/1 | Company | ||
| 18 | Medicare Supplement Insurance Experience Exhibit | 1 | EO | xxx | 3/1 | NAIC | ||
| 19 | Medicare Part D Coverage Supplement | 1 | EO | 1 | 3/1, 5/15, 8/15, 11/15 | NAIC | ||
| 20 | Property/Casualty Supplement due March 1 | xxx | EO | xxx | 3/1 | NAIC | ||
| 21 | Property/Casualty Supplement due April 1 | xxx | EO | xxx | 4/1 | NAIC | ||
| 22 | Risk-Based Capital Report | 1 | EO | 1 | 3/1 | NAIC | ||
| 23 | Schedule SIS | 1 | N/A | N/A | 3/1 | NAIC | ||
| 24 | Supplemental Compensation Exhibit | 1 | N/A | 1 | 3/1 | NAIC | ||
III. ELECTRONIC FILING REQUIREMENTS | ||||||||
| 40 | Annual Statement Electronic Filing | xxx | 1 | xxx | 3/1 | NAIC | ||
| 41 | March .PDF Filing | xxx | 1 | xxx | 3/1 | NAIC | ||
| 42 | Risk-Based Capital Electronic Filing | xxx | 1 | N/A | 3/1 | NAIC | ||
| 43 | Risk-Based Capital PDF Filing | xxx | 1 | N/A | 3/1 | NAIC | ||
| 44 | Supplemental Electronic Filing | xxx | 1 | xxx | 4/1 | NAIC | ||
| 45 | Supplemental .PDF Filing | xxx | 1 | xxx | 4/1 | NAIC | ||
| 46 | June .PDF Filing | xxx | 1 | xxx | 5/31 | NAIC | ||
| 47 | Quarterly Electronic Filing | xxx | 1 | xxx | 5/15, 8/15, 11/15 | NAIC | ||
| 48 | Quarterly .PDF Filing | xxx | 1 | xxx | 5/15, 8/15, 11/15 | NAIC | ||
IV. AUDITED FINANCIAL STATEMENTS | ||||||||
| 61 | Accountants Letter of Qualifications | 1 | EO | N/A | 6/1 | Company | See Note B | |
| 62 | Audited Financial Statements and CPA Report on Internal Controls | 1 | EO | 1 | 5/31 | Company | See Note B | |
| 63 | Audited Financial Statements Exemption Affidavit | 1 | N/A | N/A | 5/31 | Company | See Note B | |
| 64 | Communication of Internal Control Related Matters Noted in Audit | 1 | N/A | 1 | 5/31 | Company | See Note B | |
| 65 | Independent CPA (change) | 1 | N/A | N/A | 5/31 | Company | See Note B | |
| 66 | Management's Report of Internal Control Over Financial Reporting | 1 | N/A | 1 | 5/31 | Company | See Note B | |
| 67 | Notification of Adverse Financial Condition | 1 | N/A | 1 | 5/31 | Company | See Note B | |
| 68 | Report of Significant Deficiencies in Internal Controls | 1 | N/A | 1 | 5/31 | Company | See Note B | |
| 69 | Request for Exemption to File | 1 | N/A | N/A | 5/31 | Company | Call for instructions | |
V. STATE REQUIRED FILINGS | ||||||||
| 101 | New York Supplement | 1 | N/A | 1 | 3/1 | State | ||
| 102 | Electronic Filing New York Supplement | 1 | N/A | 1 | 3/1 | State | ||
| 103 | Health Insurance Claims Payable Report | 1 | N/A | 1 | 5/15, 8/15, 11/15 | |||
| 104 | Certificate of Compliance | 0 | 0 | 1 | State | See Note P | ||
| 105 | Certificate of Deposit | 0 | 0 | 1 | State | See Note Q | ||
| 106 | Certificate of Valuation | 0 | 0 | 1 | State | See Note R | ||
| 107 | Filings Checklist (with Column 1 completed) | 1 | 1 | 1 | State | |||
| 108 | Premium tax | 1 | N/A | 1 | State | |||
| 109 | Corporation Franchise Tax to Dept. Of Taxation (Copy to Department of Financial Services) | 1 | N/A | 1 | 3/15 | State | See Note S | |
**If XXX appears in this column, this state does not require this filing, if hard copy is filed with the state of domicile and if the data is filed electronically with the NAIC. If N/A appears in this column, the filing is required with the domiciliary state. EO (electronic only filing).
**If Form Source is NAIC, the form should be obtained from the appropriate vendor.
Notes and Instructions (A-S Apply to All Filings)
| A | Required
Filings Contact Person:
|
E-mail:
| |
| B | Mailing
Address:
| Annual Statement
and New York Supplement, and related items (hard copies):
Audited Annual Statements and Risk Based Capital Report:
Quarterly Statement (hard copies):
Diskettes (See Note O): Ms. Nora Dixon | |
| C | Mailing Address for Filing Fees: | N/A | |
| D | Mailing
Address for Premium Tax Payments:
| DO NOT include payments with the Annual Statement (See Note S below). | |
| E | Delivery
Instructions:
| All Department
of Financial Services filings must be physically received at the appropriate address
as indicated in NOTE B no later than the indicated due date. Companies should
file ONLY ONE COMPANY per package. The Supplement must be bound at the left side in sequential order and it must have a "COVER" page that indicates New York Supplement to the Annual Statement, the FULL Company Name and the Year. Diskettes should be labeled. | |
| F | Late
Filings:
| Failure to timely file any component of an annual, quarterly or NY Supplement filing subjects insurer to penalties set forth in NY Insurance Law Section 307 and 308. | |
| G | Original Signatures: | Actual live signatures required. | |
| H | Signature/Notarization/Certification: | Appropriate notarization required | |
| I | Amended
Filings:
| Only accepted
in accordance with the Department’s prior instructions. All amendments to your Annual Statement and/or New York Supplement must be provided in hard copy as well as an amended ELECTRONIC filing. Note: For Amended New York Supplement filings, the entire electronic filing is required. | |
| J | Exceptions from normal filings: | Only accepted in accordance with the Department’s prior instructions. | |
| K | Bar
Codes (State or NAIC)
| The NAIC Annual Statement and New York Supplement require the use of bar codes on the jurat page and certain other pages and forms. General Bar Coding instructions and a full listing of New York required bar coded forms are included on the Web site. | |
| L | NONE
Filings:
| All parts of the Annual Statement except those schedules identified by the use of "xxx" on the checklist and all parts of the New York Supplement must be accounted for. If there is nothing to report, you may complete the NAIC Annual Statement page entitled "Supplemental Exhibits and Schedules Interrogatories" INSTEAD OF filing duplicate reports marked "None". Also, you must complete the New York Supplement page entitled "Supplemental Exhibits and Schedules Interrogatories" if there is nothing to report for those New York Supplement, exhibits or schedules. You need not file reports marked "None". | |
| M | Investment Schedules: | The New York Department of Financial Services does not follow the Annual Statement Instructions related to investment schedule detail and certain supplements. As such, all items are required to be submitted in hard copy format from foreign insurers. | |
| N | Filings new, discontinued or modified materially since last year: | ||
| O | Internet Filing: | Instructions concerning
internet filing alternative to filing diskette with New York for New York Supplement
are set forth in Department Circular Letter No. 4 (2001). All companies are strongly encouraged to file national form filings (as identified in items 30, 31, 32, 33, 34, 35, 36, and 37 in the checklist) with the NAIC preferably via the Internet. By filing over the Internet or via diskette with the NAIC an insurer will have fulfilled its electronic filing requirement for national forms with New York and therefore should not file a diskette with the Department | |
| P | Certificate of Compliance: | Mr.
Daniel Sheridan, Health Bureau New York State Department of Financial Services 25 Beaver Street New York, NY 10004 | |
| Q | Certificate of Deposit: | Mr.
Daniel Sheridan, Health Bureau New York State Department of Financial Services 25 Beaver Street New York, NY 10004 | |
| R | Certificate of Valuation: | Mr.
Daniel Sheridan, Health Bureau New York State Department of Financial Services 25 Beaver Street New York, NY 10004 | |
| S | Corporation Franchise Tax to Dept. of Taxation: | A
copy of the Corporation Franchise Tax Return (CT-33) should be sent to
New York State Department of Financial Services Please note: Any payment due with the CT-33 should be sent to: NYS
Department of Taxation and Finance |
General
Instructions
For Companies to Use Checklist
Please Note:
This state’s instructions for companies to file with the NAIC are included in this Checklist. The NAIC will not be sending their own checklist this year.
Electronic Filing is intended to include filing via the Internet or filing via diskette with the NAIC. Companies that file with the NAIC via the Internet are not required to submit diskettes to the NAIC. Companies are not required to file hard copy filings with the NAIC.
Column (1) (Checklist)
Companies may use the checklist to submit to a
state, if the state requests it. Companies should copy the checklist and place
an "x" in this column when mailing information to the state.
Column
(2) (Line #)
Line # refers to a standard filing number used for easy reference.
This line number may change from year to year.
Column
(3) (Required Filings)
Name of item or form to be filed.
The Annual Statement Electronic Filing includes the annual statement data and all supplements due March 1, per the Annual Statement Instructions. This includes all detail investment schedules and other supplements for which the Annual Statement Instructions exempt printed detail.
The March .PDF Filing is the .pdf file for annual statement data, detail for investment schedules and supplements due March 1.
The Risk-Based Capital Electronic Filing includes all risk-based capital data.
The Supplemental Electronic Filing includes all supplements due April 1, per the Annual Statement Instructions.
The Supplement .PDF Filing is the .pdf file for all supplemental schedules and exhibits due April 1.
The Quarterly Electronic Filing includes the complete quarterly filing and the PDF files for all quarterly data.
The Quarterly .PDF Filing is the .pdf for quarterly statement data.
The June .PDF Filing is the .pdf file for the Audited Financial Statements.
Column
(4) (Number of Copies)
Indicates the number of copies that each foreign
or domestic company is required to file for each type of form. The Blanks (E)
Task Force modified the 1999 Annual Statement Instructions to waive paper filings
of certain NAIC supplements and certain investment schedule detail,. if such investment
schedule data is available to the states via the NAIC database. The checklists
reflect this action taken by the Blanks (EX4) Task Force. XXX appears in the “Number
of Copies” “Foreign” column for the appropriate schedules and exhibits.
Some states have chosen to waive printed quarterly and annual statements from
their foreign insurers and have chosen to rely upon the NAIC database for these
filings. This waiver could include supplemental annual statement filings. The
XXX in this column might signify that the state has waived the paper filing of
the annual statement and all supplements.
Column
(5) (Due Date)
Indicates the date on which the company must file the form.
Column
(6) (Form Source)
This column contains one of three words: "NAIC,"
"State," or "Company," If this column contains "NAIC,"
the company must obtain the forms from the appropriate vendor. If this column
contains "State," the state will provide the forms with the filing instructions
(generally on its web site). If this column contains "Company," the
company, or its representative (e.g., its CPA firm), is expected to provide the
form based upon the appropriate state instructions or the NAIC Annual Statement
Instructions.
Column (7) (Applicable Notes)
This column contains references to the Notes to the Instructions that apply to
each item listed on the checklist. The company should carefully read these notes
before submitting a filing.