NAIC & New York State Department of Financial Services

Annual Statement Checklist and Instructions 

LIFE, ACCIDENT AND HEALTH INSURERS

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

 

(1)
Check-list
 

(2)
Line #
 

(3)
REQUIRED FILINGS FOR THE ABOVE STATE
 

(4)
NUMBER OF COPIES*
 

(5)
DUE DATE
 

(6)
FORM SOURCE**
 

(7)
APPLICABLE NOTES
 

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  
 3 Separate Accounts Annual Statement (8 1/2" x 14") 

1 

EO 

1 

3/1 NAIC  
         
  

II. NAIC SUPPLEMENTS 

      
 10 Accident & Health Policy Experience Exhibit 

1 

EO 

1 

4/1 NAIC  
 11Actuarial Certification Related Annuity Nonforfeiture Ongoing Compliance for Equity Indexed Annuities
xxx

EO

xxx
3/1Company 
 12Actuarial Certifications Related to Hedging required by Actuarial Guideline XLIII
xxx
EO
xxx
3/1Company 
 13Actuarial Certification Related to Reserves required by Actuarial Guideline XLIII
xxx
EO
xxx
3/1Company 
 14Actuarial Certification regarding use 2001 Preferred Class Table
xxx
EO
xxx
3/1Company 
 15Actuarial Opinion
1 
EO
1 
3/1Company 
 16Actuarial Opinion on X-Factors
xxx

EO

xxx
3/1Company 
 17Actuarial Opinion on Separate Accounts Funding Guaranteed Minimum Benefit
xxx

EO

xxx
3/1Company 
 18Actuarial Opinion on Synthetic Guaranteed Investment Contracts
xxx

EO

xxx
3/1Company 
 19Actuarial Opinion required by Modified Guaranteed Annuity Model Regulation
xxx
EO
xxx
3/1Company 
 20Analysis of Annuity Operations by Lines of Business
xxx
EO
xxx
4/1 NAIC  
 21Analysis of Increase in Annuity Reserves During Year
xxx
EO
xxx
4/1 NAIC  
 22Credit Insurance Experience Exhibit 

1 

EO 

xxx 

4/1 NAIC  
 23 Financial Officer Certification Related to Clearly Defined Hedging Strategy required by Actuarial Guideline XLIII 
xxx
EO 
xxx
3/1Company 
 24 Health Care Exhibit (Parts 1, 2 and 3) Supplement 
xxx
EO 
xxx
4/1 NAIC  
 25 Health Care Exhibit's Allocation Report Supplement 
xxx
EO 
xxx
4/1 NAIC  
 26Interest Sensitive Life Insurance Products Report 

1 

EO 

xxx 

4/1 NAIC  
 27Investment Risk Interrogatories  

1 

EO 

1 

4/1 NAIC  
 28Life, Health & Annuity Guaranty Assessment Base Reconciliation Exhibit 

1 

EO 

xxx 

4/1 NAIC  
 29Life, Health & Annuity Guaranty Assessment Base Reconciliation Exhibit Adjustment Form 

1 

EO 

xxx 

4/1 NAIC  
 30Long Term Care Experience Reporting Forms 

1 

EO 

xxx 

4/1 NAIC  
 31Management Certification that the Valuation Reflects Management's Intent required by Actuarial Guideline XLIII 
xxx
EO 
xxx
3/1 Company  
 32Management Discussion & Analysis 

1 

EO 

1 

4/1 Company  
 33Medicare Supplement Insurance Experience Exhibit 

1 

EO 

xxx 

3/1 NAIC  
 34Medicare Part D Coverage Supplement 

1 

EO 

1 

3/1, 5/15, 8/15, 11/15 NAIC  
 35Reasonableness of Assumptions Certification 

xxx

EO 

xxx

5/15, 8/15, 11/15 Company  
 36Reasonableness & Consistency of Assumptions Cert. 

xxx

EO 

xxx

5/15, 8/15, 11/15 Company  
 37Reasonableness of Assumptions Cert. for Implied Guaranteed Rate Method 

xxx

EO 

xxx

5/15, 8/15, 11/15 Company  
 38Reasonableness & Consistency of Assumptions Cert. (Updated Average Market Value) 

xxx

EO 

xxx

5/15, 8/15, 11/15 Company  
 39Reasonableness & Consistency of Assumptions Cert. (Updated Market Value) 

xxx

EO 

xxx

5/15, 8/15, 11/15 Company  
 40Risk-Based Capital Report 

1 

EO 

1 

3/1 NAIC Note P 
 41RBC Certification required under C-3 Phase I
xxx

EO

xxx
3/1Company 
 42RBC Certification required under C-3 Phase II
xxx

EO

xxx
3/1Company 
 43Schedule SIS 

1 

N/A 

N/A 

3/1 NAIC  
 44Statement on non-guaranteed elements - Exhibit 5 Int. #3 

1 

EO 

1 

3/1 Company  
 45Statement on par/non-par policies – Exhibit 5 Int. 1&2

1 

EO 

1 

3/1 Company  
 46Supplemental Compensation Exhibit 

1 

N/A 

N/A 

3/1 NAIC  
 47Supplemental Schedule O 

1 

EO 

xxx 

3/1 NAIC  
 48Trusteed Surplus Statement (Aliens) 

1 

EO 

1 

3/1, 5/15, 8/15, 11/15 NAIC  
 49Workers’ Compensation Carve Out Supplement 

1 

EO 

1 

3/1 NAIC  
         
  

III. ELECTRONIC FILING REQUIREMENTS 

      
 50 Annual Statement Electronic Filing 

xxx 

1 

xxx 

3/1 NAIC  
 51 March .PDF Filing 

xxx 

1 

xxx 

3/1 NAIC  
 52 Risk-Based Capital Electronic Filing 

xxx 

1 

N/A 

3/1 NAIC  
 53 Risk-Based Capital .PDF Filing 

xxx 

1 

N/A 

3/1 NAIC  
 54 Separate Accounts Electronic Filing 

xxx 

1 

xxx 

3/1 NAIC  
 55Separate Accounts .PDF Filing 

xxx 

1 

xxx 

3/1 NAIC  
 56Supplemental Electronic Filing 

xxx 

1 

xxx 

4/1 NAIC  
 57Supplemental .PDF Filing 

xxx 

1 

xxx 

4/1 NAIC  
 58 Quarterly Electronic Filing 

xxx 

1 

xxx 

5/15, 8/15, 11/15 NAIC  
 59Quarterly .PDF Filing 

xxx 

1 

xxx 

5/15, 8/15, 11/15 NAIC  
 60 June .PDF Filing 

xxx 

1 

xxx 

5/31 NAIC  
         
  

IV. AUDITED/INTERNAL CONTROL RELATED REPORTS 

      
 71 Accountants Letter of Qualifications 

1 

EO 

N/A 

5/31 Company  
 72 Audited Financial Statements & CPA Report on Internal Controls 

1 

EO 

1 

5/31 Company Note S 
 73 Audited Financial Statements Exemption Affidavit 

1 

N/A 

N/A 

5/31 Company  
 74 Communication of Internal Control Related Matters Noted in Audit
1
N/A 
1
5/31 Company  
 75Independent CPA (change)

1 

N/A 

N/A 

5/31 Company  
 76Management's Report of Internal Control Over Financial Reporting
1
N/A 
1
5/31 Company  
 77Notification of Adverse Financial Condition 

1 

N/A 

1 

5/31 Company  
 78Request for Exemption to File 

1 

N/A 

N/A 

5/31 Company  
 79Relief from the five-year rotation requirement for lead audit partner

1 

EO

1 

3/1Company  
 80Relief from the one-year cooling off period for independent CPA

1 

EO

1

3/1Company  
 81Relief from the Requirements for Audit Committees

0 

EO

1 

3/1 Company  
 82Independent CPA Assessment of Internal Controls Relative to Derivatives (where applicable) 

1 

N/A 

1

5/31 Company Note T 
         
  

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 Certificate of Compliance 

0 

0 

0 

 State  
 104 Certificate of Deposit 

0 

0 

0 

 State  
 105 Certificate of Valuation 

0 

0 

1 

 State Note Q 
 106 Filings Checklist (with Column 1 completed) 

1 

0 

1 

 State  
 107 Corporation Franchise Tax to Dept. Of Taxation (Copy to Department of Financial Services) 

1 

N/A 

1 

3/15 State Note R 

*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-T Apply to All Filings)

 A Required Filings Contact Person:

 

Mr. Stephen Pallas, Life Bureau
New York State Department of Financial Services
25 Beaver Street
New York, NY 10004
(212) 480-4765

E-mail: Stephen.Pallas@dfs.ny.gov
When answering by e-mail, please include telephone number.
 

 B Mailing Address:

 

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

Ms. Valerie Jones, Life Bureau
New York State Department of Financial Services
25 Beaver Street
New York, NY 10004

QUARTERLY STATEMENT (Hard copies):

Ms. Valerie Jones, Life 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:

 

DO NOT include payments with the Annual Statement (See Note R 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 Website. 
 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: 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 50 through 60 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 Risk-Based Capital Report: Ms. Valerie Jones, Life Bureau
New York State Department of Financial Services
25 Beaver Street
New York, NY 10004
 
 Q Certificate of Valuation: Ms. Valerie Jones, Life Bureau
New York State Department of Financial Services
25 Beaver Street
New York, NY 10004
 
 R 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
Taxes and Accounts Bureau
One Commerce Plaza
Albany, NY 12257

Please note: Any payment due with the CT-33 should be sent to:

NYS Department of Taxation and Finance
Corporation Tax Bureau
State Campus
Washington Avenue
Albany, New York 12227

 S Audited Financial Statements Ms. Valerie Jones, Life Bureau
New York State Department of Financial Services
25 Beaver Street
New York, NY 10004
 
 T Independent CPA Assessment of Internal Controls Relative to Derivatives (where applicable) Ms. Ruth Gumaer, Life Bureau
New York State Department of Financial Services
25 Beaver Street
New York, NY 10004
 

  

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 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 Separate Accounts Electronic Filing includes the separate accounts annual statement and investment schedule detail.

The Separate Accounts .PDF Filing is the .pdf file for the separate accounts annual statement and all investment schedule detail.

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 quarterly statement 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.

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.

 HOME |   RETURN TO MAIN PAGERETURN TO INSURER PAGENAIC