NAIC & New York State Department of Financial Services

Annual Statement Checklist and Instructions 

PROPERTY & CASUALTY INSURERS

COMPANY NAME:                                                                                       NAIC Company Code:                   
Contact:                                                                                                           Telephone:                                       
REQUIRED FILINGS IN THE STATE OF NEW YORK                         Filings Made During the Year 2013

 

(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 

 Alien Accredited*** 

   

State

 NAIC 

State

State

   
  

I. NAIC FINANCIAL STATEMENTS

       
 1Annual Statement (8 1/2" x 14")

1

EO

xxx

1

3/1NAIC

RRG's - Submit hard copies. See NOTE P

Foreign Companies - See NOTE K

 1.1Printed Investment Schedule detail (Pages E01-E27)

1

EO

xxx

N/A

3/1NAICRRG's - Submit hard copies. See NOTE P
 2Quarterly Financial Statement (8 1/2" x 14")

1

EO

xxx

1

5/15, 8/15,
11/15
NAIC

RRG's - See NOTE P

Foreign Companies - See NOTE K

 3Protected Cell Annual Statement

1

0

xxx

N/A

3/1NAIC 
 4Combined Annual Statement (8 1/2" x 14")

1

EO

xxx

N/A

5/1NAIC 
          
  

II. NAIC SUPPLEMENTS

       
 10Accident & Health Policy Experience Exhibit

1

EO

xxx

N/A

4/1NAIC 
 11Actuarial Opinion

1

EO

xxx

1

3/1Company RRG's - Submit hard copies. See NOTE P
 12Actuarial Opinion Summary

1

N/A

N/A

N/A

3/15Company NOTE B
 13Bail Bond Supplement

1

EO

xxx

N/A

3/1NAIC 
 14Combined Insurance Expense Exhibit

1

EO

xxx

N/A

5/1NAIC 
 15Credit Insurance Experience Exhibit

1

EO

xxx

N/A

4/1NAIC 
 16Director and Officer Supplement

1

EO

xxx
N/A
5/15, 8/15, 11/15NAIC 
 17Exceptions to Reinsurance Attestation Supplement

1

N/A

N/A
N/A
3/1Company  
  18Financial Guaranty Insurance Exhibit

1

EO

xxx

N/A

3/1 NAIC  
  19Health Care Exhibit (Parts 1, 2 and 3) Supplement

1

EO

xxx

N/A

4/1 NAIC  
  20Health Care Exhibit's Allocation Report Supplement

1

EO

xxx

N/A

4/1 NAIC  
  21Investment Risk Interrogatories

1

EO

xxx

N/A

4/1 NAIC  
  22Insurance Expense Exhibit

1

EO

xxx

N/A

4/1 NAIC  
  23Long Term Care Experience Reporting Forms

1

EO

xxx

N/A

4/1 NAIC  
  24Management Discussion & Analysis

1

EO

xxx

N/A

4/1 Company  
  25Medicare Supplement Insurance Experience Exhibit

1

EO

xxx

N/A

3/1 NAIC  
  26Medicare Part D Coverage Supplement

1

EO

xxx

N/A

3/1, 5/15,
8/15, 11/15
NAIC  
  27Premiums Attributed to Protected Cells Exhibit

1

EO

xxx

N/A

3/1 NAIC  
  28Reinsurance Attestation Supplement

1

EO

xxx

N/A

3/1 Company  
  29Reinsurance Summary Supplemental

1

EO

xxx

N/A

3/1 NAIC  
  30Risk-Based Capital Report

1

EO

xxx

N/A

3/1 NAIC  
  31Schedule SIS

1

N/A

N/A

N/A

3/1 NAIC  
 32Supplement A to Schedule T

1

EO

xxx

N/A

3/1, 5/15,
8/15, 11/15
NAIC 
 33Supplemental Compensation Exhibit

1

N/A

N/A

N/A

3/1NAIC 
 34Trusteed Surplus Statement

1

EO

xxx

1

3/1, 5/15,
8/15, 11/15
NAIC 
          
  

III. ELECTRONIC FILING REQUIREMENTS

       
 50Annual Statement Electronic Filing

xxx

1

xxx

N/A

3/1NAIC
 51March .PDF Filing

xxx

1

xxx

N/A

3/1NAIC 
 52Risk-Based Capital Electronic Filing

xxx

1

xxx

N/A

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

xxx

1

xxx

N/A

3/1NAIC 
 54Combined Annual Statement Electronic Filing

xxx

1

xxx

N/A

5/1NAIC 
 55Combined Annual Statement .PDF Filing

xxx

1

xxx

N/A

5/1NAIC 
 56Supplemental Electronic Filing

xxx

1

xxx

N/A

4/1NAIC 
 57Supplemental .PDF Filing

xxx

1

xxx

N/A

4/1NAIC 
 58Quarterly Statement Electronic Filing

xxx

1

xxx

N/A

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

xxx

1

xxx

N/A

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

xxx

1

 xxx

N/A

5/31NAIC 
          
  

IV. AUDIT/INTERNAL CONTROL RELATED REPORTS

       
 71Accountants Letter of Qualifications

1

EO

N/A

N/A

5/31Company 
 72Audited Financial Reports

1

EO

xxx

N/A

5/31CompanyRRG's - Submit hard copies. See NOTE P
 73Audited Financial Reports Exemption Affidavit

1

N/A

N/A

N/A

5/31Company 
 74Communication of Internal Control Related Matters Noted in Audit

1

N/A

1

N/A

5/31CompanyForeign Companies. See NOTE Q
 75Independent CPA (change)

1

N/A

N/A

N/A

See Note RCompanySee Note R
 76Management's Report of Internal Control Over Financial Reporting

1

N/A

N/A

N/A

5/31Company 
 77Notification of Adverse Financial Condition

1

N/A

1

N/A

See Note SCompanySee Note S
 78Report of Significant Deficiencies in Internal Controls

1

N/A

1

N/A

5/31CompanyForeign Companies - See NOTE Q
 79Request for Exemption to File

1

N/A

N/A

N/A

Prior to 12/31Company 
 80Request to File Consolidated Audited Annual Statements

1

N/A

N/A

N/A

12/31Company 
          
  

V. STATE REQUIRED FILINGS

       
 101New York Supplement

1

0

1

N/A

3/1StateForeign Companies - See NOTE K; RRG's See NOTE P
 102Electronic Filing New York Supplement

1

0

1

N/A

3/1State 
 103Certificate of Compliance

1

0

1

N/A

3/1State 
 104Certificate of Deposit

1

0

1

N/A

3/1State 
 105Filings Checklist (with Column 1 completed)

1

0

1

1

3/1State 
 106Corporation Franchise Tax to Dept. of Taxation (copy to Department of Financial Services)
1

0

1

N/A

3/15StateNOTE O
 

107

Signed Notarized Jurat (Annual NAIC Blank & New York Supplement)

1

0

1

N/A

3/1NAIC / State

Foreign Companies - See NOTE K

RRG's - Submit hard copies. See NOTE P

 

107(a)

Signed Notarized Jurat (Quarterly)

1

0

1

N/A

5/15, 8/15,
11/15
NAIC

Foreign Companies - See NOTE K

RRG's - Submit hard copies. See NOTE P

 108Special Risk Schedule C-1
(http://www.dfs.ny.gov/insurance/ftz/ftz_app.htm)

1

N/A

1

N/A

5/15, 8/15,
11/15
StateApplicable to Article 63 licensee. see Note B and Note T

*If XXX appears in this column, this state does not require this filing, if hard/electronic 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.

***Lloyds should follow the Department's prior instructions.

  Notes and Instructions (A-S Apply to All Filings)

 A Required Filings Contact Person:

 

Mr. Gilbert Denton, Senior Insurance Examiner
New York State Department of Financial Services
Property Bureau - 4th Floor
One State Street
New York, NY 10004
(212) 480-4669

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

 B Mailing Address:

 

Annual Statement, New York Supplement, and related items (hard copies); Audited Financial Statement; Quarterly Statement (hard copies); Risk-Based Capital Report; Certificate of Compliance; and Certificate of Deposit:

Mr. Gilbert Denton, Senior Insurance Examiner
New York State Department of Financial Services
Property Bureau - 6th Floor
One State Street
New York, NY 10004

Note: All Risk Retention Groups should be sent directly to:

Mr. Richard Yuen, Associate Insurance Examiner
New York State Department of Financial Services
Property Bureau - Excess Line Unit
One State Street, 6th Floor
New York, NY 10004
(212) 480-5457

E-mail: Richard.Yuen@dfs.ny.gov

Actuarial Opinion Summary send directly to:

Ms. Gloria Huberman, Deputy Chief Actuary
New York State Department of Financial Services
Property Bureau - 4th Floor
One State Street
New York, NY 10004

Diskettes (See Note N):

Ms. Nora Dixon
New York State Department of Financial Services
Information Technology Services
One State Street
New York, NY 10004

 C Mailing Address for Filing Fees:  N/A 
 D 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. If the due date falls on a weekend or a legal holiday, then the filing must be received by the Department by the end of the next business day.

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.

 ELate 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.

New York statute does not provide for any extensions in the filing deadlines for Annual Statements. Further, extensions for the filing of audited financial statements are only provided upon written application by the insurer to the superintendent, and such extension is only granted if the superintendent finds that compliance would constitute a financial or organizational hardship, as provided in Section 307(b)(3) of the Insurance Law.

 FOriginal Signatures:  Actual live signatures required. 
 GSignature/Notarization/Certification:  Appropriate notarization required on the actual document.
 H 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. Foreign insurers can file electronically.

Note: For Amended New York Supplement filings, the entire electronic filing is required.

 I Exceptions from normal filings:  Only accepted in accordance with the Department’s prior instructions. 
 J 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. In addition, the Department requires the Audited Financial Statements and the documents submitted pursuant to Regulation 118 to be bar coded. General Bar Coding instructions and a full listing of New York required bar coded forms are included on the web site. 
 K Signed Jurat:

 

Foreign Companies - Refer to - Supplement No. 1 to Circular Letter No. 4 (2001) dated February 6, 2008, which can be found at the following link: http://www.dfs.ny.gov/insurance/circltr/2008/cl08_04s1.htm

Hard copy filings of the signed notarized jurat page should be directed to:

Mr. Gilbert Denton, Senior Insurance Examiner
New York State Department of Financial Services
Property Bureau - 4th Floor
One State Street
New York, NY 10004

 L NONE Filings:

 

All parts of the Annual Statement except those schedules identified as N/A 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 Filings new, discontinued or modified materially since last year: None.
 N Internet Filing:

 

Instructions concerning internet filing alternative to filing diskette with New York for the New York Supplement are set forth in the Department's Circular Letter No. 4 (2001) and Supplement 1 to Circular Letter No. 4 (2001), dated 2/6/08.

All companies are strongly encouraged to file national form filings (as identified in items 50, 51, 52, 53, 54, 55, 56, 57, 58, 59 and 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.

 O Corporation Franchise Tax to Dept. of Taxation 

Mail the CT-33NL return and payment to:

NYS Corporation Tax Processing Unit
PO Box 22038
Albany NY 12201-2038

Also mail a copy to:

NYS Department of Financial Services
Taxes and Accounts Bureau
One Commerce Plaza
Albany, NY 12257

 P Risk Retention Groups 

All RRG's are asked to submit hard copy filings for the filings identified in items 1, 1.1, 11, 28 and 72. For Quarterly Financial Statement filings (Item 2), electronic filings with the NAIC via the internet are acceptable, provided that a hard copy filing of the signed notarized jurat page is submitted. These filings and all other filings made by RRG's should be sent directly to;

Mr. Richard Yuen, Associate Insurance Examiner
New York State Department of Financial Services
Property Bureau - Excess Line Unit

One State Street, 6th Floor
New York, NY 10004
(212) 480-5457

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

Note: The New York Supplement (Items # 101 and 102) are not required filings for Foreign RRG's.

 Q Communication of Internal Control Related Matters Noted in Audit and Report of Significant Deficiencies in Internal Controls

Foreign Companies may submit via E-mail to: specialprojectsprp@dfs.ny.gov

 R Independent CPA (change): 

Provide updated information (name, address, telephone number and e-mail address) within 60 days of any change in CPA. See Regulation 118, Section 89.4(c) for additional reporting requirements if the CPA is dismissed or resigns.

 SNotification of Adverse Financial Condition:

Required to be furnished, in writing, to the Superintendent, within five business days of any determination by the CPA that the Company has materially misstated its financial condition as reported to the superintendent as of the balance sheet currently under audit or that the Company does not meet the minimum capital or surplus requirement of the insurance law as of that date.

 TSpecial Risk Schedule C-1

All companies that are required to file Schedule C-1 can submit the schedule electronically via e-mail to specialprojectsprp@dfs.ny.gov. The electronic Schedule C-1 can be found at the following link: http://www.dfs.ny.gov/insurance/ftz/ftz_app.htm

  

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 Risk-Based Capital .PDF Filing is the .pdf file for 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 Statement Electronic Filing includes the complete quarterly statement data.

The Quarterly Statement .PDF Filing is the .pdf file for quarterly statement data.

The Combined Annual Statement Electronic Filing includes the required pages of the combined annual statement and the combined Insurance Expense Exhibit.

The Combined Annual Statement .PDF Filing is the .pdf file for the Combined annual statement data and the combined Insurance Expense Exhibit.

The June .PDF Filing is the .pdf file for the Audited Financial Statements and Accountants Letter of Qualifications.

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 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.

 

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