NAIC & New York State Department of Financial Services

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 2014

(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

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

1

EO

1

3/1NAIC 
 1.1Printed Investment Schedule detail (Pages E01-E27)

1

EO

1

3/1NAIC 
 2Quarterly Financial Statement (8 1/2" x 14")

1

EO

1

5/15, 8/15, 11/15NAIC 
         
  

II. NAIC SUPPLEMENTS

      
 10Accident & Health Policy Experience Exhibit

1

EO

1

4/1NAIC 
 11Actuarial Opinion

1

EO

1

3/1Company 
 12Health Care Exhibit (Parts 1, 2 and 3) Supplement

1

EO

1

4/1NAIC 
 13Health Care Exhibit's Allocation Report Supplement

1

EO

1

4/1NAIC 
 14Investment Risk Interrogatories

1

EO

1

4/1NAIC 
   15Life Supplemental Data due March 1

xxx

EO

xxx

3/1 NAIC   
   16Life Supp Statement non-guaranteed elements -Exh 5, Int. #3

xxx

EO

xxx

3/1 Company  
   17Life Supp Statement on par/non-par policies - Exh 5 Int. 1&2

xxx

EO

xxx

3/1 Company  
   18Life Supplemental Data due April 1

xxx

EO

xxx

4/1 NAIC   
   19Long Term Care Experience Reporting Forms

1

EO

xxx

4/1 NAIC   
   20Management Discussion & Analysis

1

EO

1

4/1 Company   
   21Medicare Supplement Insurance Experience Exhibit

1

EO

xxx

3/1 NAIC   
   22Medicare Part D Coverage Supplement

1

EO

1

3/1, 5/15, 8/15, 11/15NAIC   
   23Property/Casualty Supplement due March 1

xxx

EO

xxx

3/1 NAIC   
   24Property/Casualty Supplement due April 1

xxx

EO

xxx

4/1 NAIC   
   25Risk-Based Capital Report

1

EO

1

3/1 NAIC   
   26Schedule SIS

1

N/A

N/A

3/1 NAIC   
   27Supplemental Compensation Exhibit

1

N/A

1

3/1 NAIC    
         
  

III. ELECTRONIC FILING REQUIREMENTS

      
 50Annual Statement Electronic Filing

xxx

EO

xxx

3/1NAIC 
 51March .PDF Filing

xxx

EO

xxx

3/1NAIC 
 52Risk-Based Capital Electronic Filing

xxx

EO

N/A

3/1NAIC 
 53Risk-Based Capital PDF Filing

xxx

EO

N/A

3/1NAIC 
54Supplemental Electronic Filing

xxx

EO

xxx

4/1NAIC 
 55Supplemental .PDF Filing

xxx

EO

xxx

4/1NAIC 
 56Quarterly Statement Electronic Filing

xxx

EO

xxx

5/15, 8/15, 11/15NAIC 
 57Quarterly .PDF Filing

xxx

EO

xxx

5/15, 8/15, 11/15NAIC 
 58June .PDF Filing

xxx

EO

xxx

6/1NAIC 
         
  

IV. AUDITED FINANCIAL STATEMENTS

      
 71Accountants Letter of Qualifications

1

EO

N/A

6/1CompanySee Note B
 72Audited Financial Statements

1

EO

1

5/31CompanySee Note B
 73Audited Financial Statements Exemption Affidavit

1

N/A

N/A

 CompanySee Note B
 74Communication of Internal Control Related Matters Noted in Audit

1

N/A

1

8/1CompanySee Note B
 75Independent CPA (change)

1

N/A

N/A

 CompanySee Note B
 76Management's Report of Internal Control Over Financial Reporting

1

N/A

1

8/1CompanySee Note B
 77Notification of Adverse Financial Condition

1

N/A

1

 CompanySee Note B
 78Request for Exemption to File

1

N/A

N/A

 CompanyCall for instructions
 79Relief from the five-year rotation requirement for lead audit partner

1

EO

1

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

1

EO

1

3/1CompanyCall for instructions
 81Relief from the Requirements for Audit Committees

1

EO

1

3/1CompanyCall for instructions
         
  

V. STATE REQUIRED FILINGS

      
 101New York Supplement

1

N/A

1

3/1State 
 102Electronic Filing New York Supplement

1

N/A

1

3/1State 
 103 New York Quarterly Supplement

1

N/A

1

5/15, 8/15, 11/15State 
 104Health Insurance Claims Payable Report

1

N/A

1

5/15, 8/15, 11/15State 
 105Certificate of Compliance

0

0

1

 StateSee Note P
 106Certificate of Deposit

0

0

1

 StateSee Note Q
 107Certificate of Valuation

0

0

1

 StateSee Note R
 108Filings Checklist (with Column 1 completed)

1

1

1

 State 
 109Premium tax

1

N/A

1

 State 
 110Corporation Franchise Tax to Dept. Of Taxation (Copy to Department of Financial Services)

1

N/A

1

3/15StateSee 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.

*** For those states that have adopted the NAIC updated Holding Company Model Act, a Form F filing is required annually by holding company groups. Consistent with the Form B filing requirements, the Form F is a state filing only and should not be submitted by the company to the NAIC. Note however that this filing is intended to be submitted to the lead state. For more information on lead states, see the following NAIC URL: http://www.naic.org/public_lead_state_report.htm.

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

 ARequired Filings Contact Person:

 

Mr. Daniel Sheridan, Health Bureau
New York State Department of Financial Services
One State Street
New York, NY 10004
(212) 480-6093

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

 BMailing Address:

 

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

Ms. Christine Gralton, Health Bureau
New York State Department of Financial Services
One State Street
New York, NY 10004

Audited Annual Statements and Risk Based Capital Report:

Ms. Christine Gralton, Health Bureau
New York State Department of Financial Services
One State Street
New York, NY 10004

Quarterly Statement (hard copies):

Ms. Christine Gralton, Health Bureau
New York State Department of Financial Services
One State Street
New York, NY 10004

Diskettes (See Note O):

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

 

 CMailing Address for Filing Fees:N/A
 DMailing Address for Premium Tax Payments:

 

DO NOT include payments with the Annual Statement (See Note S below).
 EDelivery 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.

 FLate 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.
 GOriginal Signatures: Actual live signatures required.
 HSignature/Notarization/Certification: Appropriate notarization required
 IAmended 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.

 JExceptions from normal filings:Only accepted in accordance with the Department’s prior instructions.
 KBar 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.
 LNONE 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".
 MInvestment 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.
 NFilings new, discontinued or modified materially since last year: 
 OInternet 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

 PCertificate of Compliance:Ms. Christine Gralton, Health Bureau
New York State Department of Financial Services
One State Street
New York, NY 10004
 QCertificate of Deposit:Ms. Christine Gralton, Health Bureau
New York State Department of Financial Services
One State Street
New York, NY 10004
 RCertificate of Valuation:Ms. Christine Gralton, Health Bureau
New York State Department of Financial Services
One State Street
New York, NY 10004
 SCorporation 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
Revenue and Expenses
One Commerce Plaza
Albany, New York 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

  

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 Electronic 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 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.  

 

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