NAIC & New York State Department of Financial Services

Annual Statement Filing Checklist and Instructions 


COMPANY NAME:                                                                     NAIC Company Code:                   
Contact:                                                                                         Telephone:                                       
REQUIRED FILINGS IN THE STATE OF NEW YORK       Filings Made During the Year 2012



Line #












 1 Annual Statement (8 1/2" X 14") 1 EO  3/1 NAIC  
 1.1 Printed Investment Schedule detail (Pages E01-E27) 1 EO  3/1 NAIC  
 2 Quarterly Financial Statement (8 1/2" x 14") 2 EO  5/15, 8/15, 11/15 NAIC  
 10 Accident & Health Policy Experience Exhibit 1 EO  4/1 NAIC  
 11 Actuarial Opinion 1 EO  3/1 Company  
 12 Investment Risk Interrogatories 1 EO  4/1 NAIC  
 13 Life Supplement xxx EO  3/1 NAIC  
 14 Long-term Care Experience Reporting Forms 1 EO  4/1 NAIC  
 15 Management Discussion & Analysis 1 EO  4/1 Company  
 16 Medicare Supplement Insurance Experience Exhibit 1 EO  3/1 NAIC  
 17 Medicare Part D Coverage Supplement 1 EO  3/1, 5/15, 8/15, 11/15 NAIC  
 18 Property/Casualty Supplement xxx EO  3/1 NAIC  
 19 Risk-Based Capital Report 1 EO  3/1 NAIC  
 20 Supplemental Compensation Exhibit 1 N/A  3/1 NAIC  
 21Health Care Exhibit (Parts 1, 2 and 3) Supplement 1 EO 4/1 NAIC  
 22Health Care Exhibit's Allocation Report Supplement 1 EO 4/1 NAIC  
 30 Annual Statement Electronic Filing xxx 1  3/1 NAIC  
 31 March .PDF Filing xxx 1  3/1 NAIC  
 32 Risk-Based Capital Electronic Filing xxx 1  3/1 NAIC  
 33 Supplemental Electronic Filing xxx 1  4/1 NAIC  
 34 Supplemental .PDF Filing xxx 1  4/1 NAIC  
 35 June .PDF Filing xxx 1  5/31 NAIC  
 36 Quarterly Electronic Filing xxx 1  5/15, 8/15, 11/15 NAIC  
 37 Quarterly .PDF Filing xxx 1  5/15, 8/15, 11/15 NAIC  
 51 Accountants Letter of Qualifications 1 N/A  Company See Note B 
 52 Audited Financial Statements 1 EO  5/31 Company See Note B 
 53 Audited Financial Statements Exemption Affidavit  N/A   Company See Note B 
 54 Communication of Internal Control Related Matters Noted in Audit1 N/A  5/31 Company See Note B 
 55 Independent CPA (change) 1 N/A  5/31 Company See Note B 
 56 Management's Report of Internal Control Over Financial Reporting 1 N/A  5/31 Company See Note B 
 57Notification of Adverse Financial Condition 1 N/A  5/31 Company See Note B 
 58Report of Significant Deficiencies in Internal Controls 1 N/A  5/31 Company See Note B 
 59Request for Exemption to File 1 N/A   Company  
 101 New York Annual Supplement 1 N/A  3/1 State  
 102 New York Quarterly Supplement 2 N/A  5/15, 8/15, 11/15 State  
 103 New York Annual Supplement Electronic Filing 1 N/A  3/1 State  
 104 New York Quarterly Supplement Electronic Filing 1 N/A  5/15, 8/15, 11/15 State  
 105 Filings Checklist (with Column 1 completed) 1 0  3/1 State  

*If XXX appears in this column, this state does not require this filing, providing 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-O Apply to All Filings)

 A Required Filings Contact Person:


Ms K. Daisy Wong, Health Bureau
New York State Department of Financial Services
25 Beaver Street
New York, NY 10004
(212) 480-5062

When answering by e-mail, please include telephone number.

 B Mailing Address:


Annual Statement and New York Supplement, and related items (hard copies):

Mr. Daniel Sheridan, Health Bureau
New York State Department of Financial Services
25 Beaver Street
New York, NY 10004

Audited Annual Statements:

Mr. Daniel Sheridan, Health Bureau
New York State Department of Financial Services
25 Beaver Street
New York, NY 10004

Quarterly Statement and New York Quarterly Supplement (hard copies):

Mr. Daniel Sheridan, Health Bureau
New York State Department of Financial Services
25 Beaver Street
New York, NY 10004

Diskettes (See Note O):

Ms. Nora Dixon
Insurance Regulatory Systems Bureau
New York State Department of Financial Services
25 Beaver Street
New York, NY 10004


 C Mailing Address for Filing Fees:  N/A 
 D Mailing Address for Premium Tax Payments:  N/A 
 E Delivery Instructions:


All Department 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 NAIC Statement and 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 and Quarterly 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 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: Investment Schedules required for all filings. 
 N Filings new, discontinued or modified materially since last year: Instructions will be provided by the Department as needed. 
 O Internet Filing: Instructions concerning internet filing alternative to filing diskette with New York for New York Supplement are set forth in the Department's 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 


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)
The checklist is a required filing. 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 Supplemental .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 file 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 the state 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.