| Annual Statement Checklist and Instructions |
ACCIDENT AND HEALTH INSURERS FILING ON THE LIFE BLANK
| COMPANY
NAME:
NAIC
Company Code:
Contact: Telephone: REQUIRED FILINGS IN THE STATE OF NEW YORK Filings Made During the Year 2013 |
(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 | ||
| 3 | Separate Accounts Annual Statement (8 1/2" x 14") | 1 | EO | 1 | 3/1 | NAIC | File if applicable | |
II. NAIC SUPPLEMENTS | ||||||||
| 10 | Accident & Health Policy Experience Exhibit | 1 | EO | 1 | 4/1 | NAIC | ||
| 11 | Actuarial Certification Related Annuity Nonforfeiture Ongoing Compliance for Equity Indexed Annuities | xxx | EO | xxx | 3/1 | Company | ||
| 12 | Actuarial Certifications Related to Hedging required by Actuarial Guideline XLIII | xxx | EO | xxx | 3/1 | Company | ||
| 13 | Actuarial Certification Related to Reserves required by Actuarial Guideline XLIII | xxx | EO | xxx | 3/1 | Company | ||
| 14 | Actuarial Opinion | 1 | EO | 1 | 3/1 | Company | ||
| 15 | Actuarial Opinion on X-Factors | xxx | EO | xxx | 3/1 | Company | ||
| 16 | Actuarial Opinion on Separate Accounts Funding Guaranteed Minimum Benefit | xxx | EO | xxx | 3/1 | Company | ||
| 17 | Actuarial Opinion on Synthetic Guaranteed Investment Contracts | xxx | EO | xxx | 3/1 | Company | ||
| 18 | Actuarial Opinion required by Modified Guaranteed Annuity Model Regulation | xxx | EO | xxx | 3/1 | Company | ||
| 19 | Analysis of Annuity Operations by Lines of Business | xxx | EO | xxx | 4/1 | NAIC | ||
| 20 | Analysis of Increase in Annuity Reserves During Year | xxx | EO | xxx | 4/1 | NAIC | ||
| 21 | Credit Insurance Experience Exhibit | 1 | EO | xxx | 4/1 | NAIC | ||
| 22 | Financial Officer Certification Related to Clearly Defined Hedging Strategy required by Actuarial Guideline XLIII | xxx | EO | xxx | 3/1 | Company | ||
| 23 | Health Care Exhibit (Parts 1, 2 and 3) Supplement | 1 | EO | 1 | 4/1 | NAIC | ||
| 24 | Health Care Exhibit's Allocation Report Supplement | 1 | EO | 1 | 4/1 | NAIC | ||
| 25 | Interest Sensitive Life Insurance Products Report | 1 | EO | xxx | 4/1 | NAIC | ||
| 26 | Investment Risk Interrogatories | 1 | EO | 1 | 4/1 | NAIC | ||
| 27 | Life, Health & Annuity Guaranty Assessment Base Reconciliation Exhibit | 1 | EO | xxx | 4/1 | NAIC | ||
| 28 | Life, Health & Annuity Guaranty Assessment Base Reconciliation Exhibit Adjustment Form | 1 | EO | xxx | 4/1 | NAIC | ||
| 29 | Long Term Care Experience Reporting Forms | 1 | EO | xxx | 4/1 | NAIC | ||
| 30 | Management Certification that the Valuation Reflects Management's Intent required by Actuarial Guideline XLIII | xxx | EO | xxx | 3/1 | Company | ||
| 31 | Management Discussion & Analysis | 1 | EO | 1 | 4/1 | Company | ||
| 32 | Medicare Supplement Insurance Experience Exhibit | 1 | EO | xxx | 3/1 | NAIC | ||
| 33 | Medicare Part D Coverage Supplement | 1 | EO | 1 | 3/1, 5/15, 8/15, 11/15 | NAIC | ||
| 34 | Reasonableness of Assumptions Certification | xxx | EO | xxx | 5/15, 8/15, 11/15 | Company | ||
| 35 | Reasonableness & Consistency of Assumptions Cert. | xxx | EO | xxx | 5/15, 8/15, 11/15 | Company | ||
| 36 | Reasonableness of Assumptions Cert. for Implied Guaranteed Rate Method | xxx | EO | xxx | 5/15, 8/15, 11/15 | Company | ||
| 37 | Reasonableness & Consistency of Assumptions Cert. (Updated Average Market Value) | xxx | EO | xxx | 5/15, 8/15, 11/15 | Company | ||
| 38 | Reasonableness & Consistency of Assumptions Cert. (Updated Market Value) | xxx | EO | xxx | 5/15, 8/15, 11/15 | Company | ||
| 39 | Risk-Based Capital Report | 1 | EO | 1 | 3/1 | NAIC | Note P | |
| 40 | RBC Certification required under C-3 Phase I | xxx | EO | xxx | 3/1 | Company | ||
| 41 | RBC Certification required under C-3 Phase II | xxx | EO | xxx | 3/1 | Company | ||
| 42 | Schedule SIS | 1 | N/A | N/A | 3/1 | NAIC | ||
| 43 | Statement on non-guaranteed elements - Exhibit 5 Int. #3 | 1 | EO | 1 | 3/1 | Company | ||
| 44 | Statement on par/non-par policies – Exhibit 5 Int. 1&2 | 1 | EO | 1 | 3/1 | Company | ||
| 45 | Supplemental Compensation Exhibit | 1 | N/A | N/A | 3/1 | NAIC | ||
| 46 | Supplemental Schedule O | 1 | EO | xxx | 3/1 | NAIC | ||
| 47 | Trusteed Surplus Statement (Aliens) | 1 | EO | 1 | 3/1, 5/15, 8/15, 11/15 | NAIC | ||
| 48 | Workers’ 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 | ||
| 55 | Separate Accounts .PDF Filing | xxx | 1 | xxx | 3/1 | NAIC | ||
| 56 | Supplemental Electronic Filing | xxx | 1 | xxx | 4/1 | NAIC | ||
| 57 | Supplemental .PDF Filing | xxx | 1 | xxx | 4/1 | NAIC | ||
| 58 | Quarterly Electronic Filing | xxx | 1 | xxx | 5/15, 8/15, 11/15 | NAIC | ||
| 59 | Quarterly .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 | 6/1 | Company | ||
| 72 | Audited Financial Statements & CPA Report on Internal Controls | 1 | EO | 1 | 5/31 | Company | Note B | |
| 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 | ||
| 75 | Independent CPA (change) | 1 | N/A | N/A | 3/1 | Company | ||
| 76 | Management's Report of Internal Control Over Financial Reporting | 1 | N/A | 1 | 5/31 | Company | ||
| 77 | Notification of Adverse Financial Condition | 1 | N/A | 1 | 5/31 | Company | ||
| 78 | Report of Significant Deficiencies in Internal Controls | 1 | N/A | 1 | 5/31 | Company | ||
| 79 | Request for Exemption to File | 1 | N/A | N/A | 5/31 | Company | Call | |
| 80 | Independent CPA Assessment of Internal Controls Relative to Derivatives (where applicable) | 1 | N/A | 1 | 5/31 | Company | ||
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 | State | ||
| 104 | Certificate of Compliance | 0 | 0 | 0 | State | |||
| 105 | Certificate of Deposit | 0 | 0 | 0 | State | |||
| 106 | Certificate of Valuation | 0 | 0 | 1 | State | Note R | ||
| 107 | Filings Checklist (with Column 1 completed) | 1 | 0 | 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 | Note S | |
| 110 | Premiums and Enrollment by New York County | 1 | N/A | 1 | 3/1 | State | Note T | |
| 111 | Statement of Revenue and Expense By Line of Business: Parts 1, 2, 3, and 4 | 1 | N/A | 1 | 3/1 | State | Note T | |
*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:
Daniel.Sheridan@dfs.ny.gov | |
| B | Mailing
Address:
| Annual Statement
and New York Supplement, and related items (hard copies):
Audited Annual Statements and Risk Based Capital Reports:
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 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 | 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 | |
| T | Premiums and Enrollment by New York County; and Statement of Revenue and Expense By Line of Business: Parts 1, 2, 3, and 4 | These filings can be made electronically to ashealth@ins.state.ny.us or attached to the New York Supplement which is due 3/1. |
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.
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.