NAIC & New York State Department of Financial Services

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 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 

      
 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  
 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 Opinion
1 
EO
1 
3/1Company 
 15Actuarial Opinion on X-Factors
xxx

EO

xxx
3/1Company 
 16Actuarial Opinion on Separate Accounts Funding Guaranteed Minimum Benefit
xxx

EO

xxx
3/1Company 
 17Actuarial Opinion on Synthetic Guaranteed Investment Contracts
xxx

EO

xxx
3/1Company 
 18Actuarial Opinion required by Modified Guaranteed Annuity Model Regulation
xxx
EO
xxx
3/1Company 
 19Analysis of Annuity Operations by Lines of Business
xxx
EO
xxx
4/1 NAIC  
 20Analysis of Increase in Annuity Reserves During Year
xxx
EO
xxx
4/1 NAIC  
 21Credit 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
3/1Company 
 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  
 25Interest Sensitive Life Insurance Products Report 

1 

EO 

xxx 

4/1 NAIC  
 26Investment Risk Interrogatories  

1 

EO 

1 

4/1 NAIC  
 27Life, Health & Annuity Guaranty Assessment Base Reconciliation Exhibit 

1 

EO 

xxx 

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

1 

EO 

xxx 

4/1 NAIC  
 29Long Term Care Experience Reporting Forms 

1 

EO 

xxx 

4/1 NAIC  
 30Management Certification that the Valuation Reflects Management's Intent required by Actuarial Guideline XLIII 
xxx
EO 
xxx
3/1 Company  
 31Management Discussion & Analysis 

1 

EO 

1 

4/1 Company  
 32Medicare Supplement Insurance Experience Exhibit 

1 

EO 

xxx 

3/1 NAIC  
 33Medicare Part D Coverage Supplement 

1 

EO 

1 

3/1, 5/15, 8/15, 11/15 NAIC  
 34Reasonableness of Assumptions Certification 

xxx

EO 

xxx

5/15, 8/15, 11/15 Company  
 35Reasonableness & 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  
 37Reasonableness & Consistency of Assumptions Cert. (Updated Average Market Value) 

xxx

EO 

xxx

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

xxx

EO 

xxx

5/15, 8/15, 11/15 Company  
 39Risk-Based Capital Report 

1 

EO 

1 

3/1 NAIC Note P 
 40RBC Certification required under C-3 Phase I
xxx

EO

xxx
3/1Company 
 41RBC Certification required under C-3 Phase II
xxx

EO

xxx
3/1Company 
 42Schedule SIS 

1 

N/A 

N/A 

3/1 NAIC  
 43Statement on non-guaranteed elements - Exhibit 5 Int. #3 

1 

EO 

1 

3/1 Company  
 44Statement on par/non-par policies – Exhibit 5 Int. 1&2

1 

EO 

1 

3/1 Company  
 45Supplemental Compensation Exhibit 

1 

N/A 

N/A 

3/1 NAIC  
 46Supplemental Schedule O 

1 

EO 

xxx 

3/1 NAIC  
 47Trusteed Surplus Statement (Aliens) 

1 

EO 

1 

3/1, 5/15, 8/15, 11/15 NAIC  
 48Workers’ Compensation Carve Out Supplement 

1 

EO 

1 

3/1 NAIC  
         
  

III. ELECTRONIC FILING REQUIREMENTS 

      
 50 Annual Statement Electronic Filing 

xxx 

EO

xxx 

3/1 NAIC  
 51 March .PDF Filing 

xxx 

EO

xxx 

3/1 NAIC  
 52 Risk-Based Capital Electronic Filing 

xxx 

EO

N/A 

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

xxx 

EO

N/A 

3/1 NAIC  
 54Supplemental Electronic Filing 

xxx 

EO

xxx 

4/1 NAIC  
 55Supplemental .PDF Filing 

xxx 

EO

xxx 

4/1 NAIC  
 56Quarterly Statement Electronic Filing 

xxx 

EO

xxx 

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

xxx 

EO

xxx 

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

xxx 

EO

xxx 

6/1NAIC  
         
  

IV. AUDITED/INTERNAL CONTROL RELATED REPORTS 

      
 71 Accountants Letter of Qualifications 

1 

EO 

N/A 

6/1 Company See Note B
 72 Audited Financial Reports 

1 

EO 

1 

6/1 Company See Note B
 73 Audited Financial Statements Exemption Affidavit 

1 

N/A 

N/A 

 Company See Note B
 74 Communication of Internal Control Related Matters Noted in Audit
1
N/A 
1
8/1 Company See Note B
 75Independent CPA (change)

1 

N/A 

N/A 

 Company See Note B
 76Management's Report of Internal Control Over Financial Reporting
1
N/A 
1
8/1 Company See Note B
 77Notification of Adverse Financial Condition 

1 

N/A 

1 

 Company See Note B
 78Request for Exemption to File 

1 

N/A 

N/A 

 Company Call for Instructions
 79Relief from the five-year rotation requirement for lead audit partner 

1 

EO

1 

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

1 

EO

1 

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

1 

EO

1 

3/1 Company Call for Instructions
         
  

V. STATE REQUIRED FILINGS 

      
 101 New York Annual Supplement 

1 

0 

1 

3/1 State  
 102 Electronic Filing New York Supplement 

1 

0

1 

3/1 State  
 103New York Quarterly Supplement 

 

0

1 

5/15, 8/15, 11/15State  
 104Electronic Filing New York Quarterly Supplement 
0
1 
5/15, 8/15, 11/15State  
 105 Certificate of Compliance 

0 

0 

1

 State See Note P
 106Certificate of Deposit 

0 

0 

1

 State See Note Q
 107Certificate of Valuation 

0 

0 

1 

 State See Note R
 108Filings Checklist (with Column 1 completed) 

1 

1

1 

 State  
 109Premium Tax

1 

N/A 

1 

 State  
 109Corporation Franchise Tax to Dept. Of Taxation (Copy to Department of Financial Services) 

1 

N/A 

1 

3/15 State See 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 Reports:

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 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. 

 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, 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

  

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 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 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.  

 

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