NAIC & New York State Department of Financial Services

Annual Statement Checklist and Instructions

FRATERNAL BENEFIT SOCIETIES

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

1

EO

1

3/1NAIC 
         
  

II. NAIC SUPPLEMENTS

      
 10Accident & Health Policy Experience Exhibit

1

EO

1

4/1NAIC 
 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 
 14.1Actuarial Memorandum Related to Universal Life with Secondary Guarantee Policies required by Actuarial Guideline XXXVIII
xxx
N/A
xxx
4/30Company 
 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
4/1NAIC 
 21Analysis of Increase in Annuity Reserves During Year
xxx
EO
xxx
4/1NAIC 
 22Financial Officer Certification Related to Clearly Defined Hedging Strategy required by Actuarial Guideline XLIII
xxx
EO
xxx
3/1Company 
 23Health Care Exhibit (Parts 1, 2 and 3) Supplement
xxx
EO
xxx
4/1NAIC 
 24Health Care Exhibit's Allocation Report Supplement
xxx
EO
xxx
4/1NAIC 
 25Interest Sensitive Life Insurance Products Report

1

EO

xxx

4/1NAIC 
 26Investment Risk Interrogatories

1

EO

1

4/1NAIC 
 27Long Term Care Experience Reporting Forms

1

EO

xxx

4/1NAIC 
 28Management Certification that the Valuation Reflects Management's Intent required by Actuarial Guideline XLIII
xxx
EO
xxx
3/1Company 
 29Management Discussion & Analysis

1

EO

1

4/1Company 
 30Medicare Supplement Insurance Experience Exhibit

1

EO

xxx

3/1NAIC 
 31Medicare Part D Coverage Supplement

1

EO

1

3/1, 5/15, 8/15, 11/15NAIC 
 32Reasonableness of Assumptions Certification
xxx

EO

xxx

5/15, 8/15, 11/15Company 
 33Reasonableness & Consistency of Assumptions Cert.
xxx

EO

xxx

5/15, 8/15, 11/15Company 
 34Reasonableness of Assumptions Cert. for Implied Guaranteed Rate Method
xxx

EO

xxx

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

EO

xxx

5/15, 8/15, 11/15Company 
 36Reasonableness & Consistency of Assumptions Cert. (Updated Market Value)
xxx

EO

xxx

5/15, 8/15, 11/15Company 
 37Risk-Based Capital Report

1

EO

1

3/1NAIC 
 38RBC Certification required under C-3 Phase I
xxx

EO

xxx
3/1Company 
 39RBC Certification required under C-3 Phase II
xxx

EO

xxx
3/1Company 
 40Statement on non-guaranteed elements – Exhibit 5 Interr. #3

1

EO

1

3/1Company 
 41Statement on participating/non-participating policies – Exhibit 5, Inter. #1&2

1

EO

1

3/1Company 
 42Supplemental Compensation Exhibit

1

N/A

N/A

3/1NAIC 
 43Trusteed Surplus Statement

1

EO

1

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

III. ELECTRONIC FILING REQUIREMENTS

      
 50Annual Statement Electronic Filing

xxx

1

xxx

3/1NAIC 
 51March .PDF Filing

xxx

1

xxx

3/1NAIC 
 52Risk-Based Capital Electronic Filing

xxx

1

N/A

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

xxx

1

N/A

3/1NAIC 
 54Separate Accounts Electronic Filing

xxx

1

xxx

3/1NAIC 
 55Separate Accounts .PDF Filing

xxx

1

xxx

3/1NAIC 
 56Supplemental Electronic Filing

xxx

1

xxx

4/1NAIC 
 57Supplemental .PDF Filing

xxx

1

xxx

4/1NAIC 
 58Quarterly Statement Electronic Filing

xxx

1

xxx

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

xxx

1

xxx

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

xxx

1

xxx

5/31NAIC 
         
  

IV. AUDITED/INTERNAL CONTROL RELATED REPORTS

      
 71Accountants Letter of Qualifications

1

EO

N/A

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

1

EO

1

5/31CompanyNote Q
 73Audited Financial Statements Exemption Affidavit

1

N/A

N/A

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

1

N/A

N/A

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

1

N/A

1

5/31Company 
 78Request for Exemption to File

1

N/A

N/A

5/31Company 
 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

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

1

N/A

1

5/31CompanyNote R
         
  

V. STATE REQUIRED FILINGS

      
 101New York Supplement

1

N/A

1

3/1State 
 102Electronic Filing New York Supplement

1

N/A

1

3/1State 
 103Certificate of Compliance

0

0

0

 State 
 104Certificate of Deposit

0

0

0

 State 
 105Certificate of Valuation

0

0

1

 StateNote P
 106Filings Checklist (with Column 1 completed)

1

0

1

 State 
 107Premium tax

1

0

1

6/1State 

*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-R Apply to All Filings)

 ARequired Filings Contact Person:

 

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

E-mail: Stephen.Pallas@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. Valerie Jones, Life Bureau
New York State Department of Financial Services
One State Street
New York, NY 10004

Quarterly Statement (hard copies):

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

Diskettes (See Note O):

Ms. Nora Dixon
Information Technology Services
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:N/A
 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, Quarterly 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 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 items 50 through 60 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

By filing items 58 and 59 over the Internet with the NAIC, an insurer will have fulfilled its electronic filing requirement for national quarterly forms with New York and therefore should not file a diskette with the Department. If the Quarterly filing is not made over the Internet, a diskette must be filed with New York.

 PCertificate of Valuation:Ms. Valerie Jones, Life Bureau
New York State Department of Financial Services
One State Street
New York, NY 10004
 QAudited Financial StatementsMs. Valerie Jones, Life Bureau
New York State Department of Financial Services
One State Street
New York, NY 10004
 RIndependent CPA Assessment of Internal Controls Relative to Derivatives (where applicable)Mr. James Matheson, Life Bureau
New York State Department of Financial Services
One State 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 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 investments 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 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 investment schedule detail.

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 supplements 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 (E) 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 website). 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