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NAIC & Department of Financial Services Annual Statement Checklist and Instructions

ACCIDENT AND HEALTH INSURERS FILING ON THE LIFE BLANK 2016

COMPANY NAME:                                                                                                            NAIC Company Code:                 
Contact:                                                                                                                                         Telephone:                        
REQUIRED FILINGS IN THE STATE OF NEW YORK                                         Filings Made During the Year 2017

 

(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 ½”x14”)

1

EO

1

3/1

NAIC

See Note B

 

1.1

Printed Investment Schedule detail (Pages E01-E28)

1

EO

1

3/1

NAIC

See Note B

 

2

Quarterly Financial Statement (8 ½” x 14”)

1

EO

1

5/15, 8/15, 11/15

NAIC

See Note B

 

3

Separate Accounts Annual Statement (8 ½”x14”)

1

EO

1

3/1

NAIC

See Note B

 

 

 

 

 

 

 

 

 

 

 

II.  NAIC SUPPLEMENTS

 

 

11

Accident & Health Policy Experience Exhibit

1

EO

1

4/1

NAIC

 

 

12

Analysis of Annuity Operations by Lines of Business

xxx

EO

xxx

4/1

NAIC

 

 

13

Analysis of Increase in Annuity Reserves During Year

xxx

EO

xxx

4/1

NAIC

 

 

14

Credit Insurance Experience Exhibit

1

EO

xxx

4/1

NAIC

 

 

15

Interest Sensitive Life Insurance Products Report

1

EO

xxx

4/1

NAIC

 

 

16

Life, Health & Annuity Guaranty Assessment Base Reconciliation Exhibit

1

EO

xxx

4/1

NAIC

 

 

17

Life, Health & Annuity Guaranty   Assessment Base Reconciliation  Exhibit Adjustment Form

1

EO

xxx

4/1

NAIC

 

 

18

Long-term Care Experience Reporting Forms

1

EO

xxx

4/1

NAIC

 

 

19

Management Discussion & Analysis

1

EO

1

4/1

Company

 

 

20

Medicare Supplement Insurance Experience Exhibit

1

EO

xxx

3/1

NAIC

 

 

21

Medicare Part D Coverage Supplement

1

EO

1

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

NAIC

 

 

22

Risk-Based Capital Report

1

EO

1

3/1

NAIC

 

 

23

Schedule SIS

1

N/A

N/A

3/1

NAIC

 

 

24

Supplemental Compensation Exhibit

1

N/A

N/A

3/1

NAIC

 

 

25

Supplemental Health Care Exhibit (Parts 1, 2 and 3)

xxx

EO

xxx

4/1

NAIC

 

 

26

Supplemental Health Care Exhibit’s Allocation Report

xxx

EO

xxx

4/1

NAIC

 

 

27

Supplemental Investment Risk   Interrogatories

1

EO

1

4/1

NAIC

 

 

28

Supplemental Schedule O

1

EO

xxx

3/1

NAIC

 

 

29

Supplemental XXX/AXXX Reinsurance Exhibit

1

EO

1

4/1

NAIC

 

 

30

Trusteed Surplus Statement (Aliens)

1

EO

1

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

NAIC

 

 

31

Workers’ Compensation Carve-Out Supplement

1

EO

1

3/1

NAIC

 

 

 

 

 

 

 

 

 

 

 

 

Actuarial Related Items

 

 

32

Actuarial Certification regarding use 2001 Preferred Class Table

xxx

EO

xxx

3/1

Company

 

 

33

Actuarial Certification Related Annuity Nonforfeiture Ongoing Compliance for Equity Indexed Annuities

xxx

EO

xxx

3/1

Company

 

 

34

Actuarial Certification Related to Hedging required by Actuarial Guideline XLIII

xxx

EO

xxx

3/1

Company

 

 

35

Actuarial Certification Related to Reserves required by Actuarial Guideline XLIII

xxx

EO

xxx

3/1

Company

 

 

36

Actuarial Memorandum Related to Universal Life with Secondary Guarantee Policies required by Actuarial   Guideline XXXVIII 8D

xxx

N/A

xxx

4/30

Company

 

 

37

Actuarial Opinion

1

EO

1

3/1

Company

See Note B

 

38

Actuarial Opinion on Separate Accounts Funding Guaranteed Minimum Benefit

xxx

EO

xxx

3/1

Company

 

 

39

Actuarial Opinion on Synthetic Guaranteed Investment Contracts

xxx

EO

xxx

3/1

Company

 

 

40

Actuarial Opinion on X-Factors

xxx

EO

xxx

3/1

Company

 

 

41

Actuarial Opinion required by Modified Guaranteed Annuity Model Regulation

xxx

EO

xxx

3/1

Company

 

 

42

Financial Officer Certification Related to Clearly Defined Hedging Strategy required by   Actuarial Guideline XLIII

xxx

EO

xxx

3/1

Company

 

 

43

Management Certification that the Valuation Reflects Management’s Intent required by Actuarial Guideline   XLIII

xxx

EO

xxx

3/1

Company

 

 

44

RAAIS required by Actuarial Opinion and Memorandum Regulation (Model 822), Section 7A(5)

1

N/A

1

3/15

Company

 

 

45

Reasonableness & Consistency of Assumptions Certification required by Actuarial   Guideline XXXV

xxx

EO

xxx

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

Company

 

 

46

Reasonableness of Assumptions Certification required by Actuarial Guideline XXXV

xxx

EO

xxx

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

Company

 

 

47

Reasonableness & Consistency of Assumptions Certification required by Actuarial   Guideline XXXVI (Updated Average Market Value)

xxx

EO

xxx

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

Company

 

 

48

Reasonableness & Consistency of Assumptions Certification required by Actuarial   Guideline XXXVI (Updated Market Value)

xxx

EO

xxx

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

Company

 

 

49

Reasonableness of Assumptions Certification for Implied Guaranteed Rate Method required by Actuarial Guideline XXXVI

xxx

EO

xxx

3/1,5/15, 8/15,   11/15

Company

 

 

50

RBC Certification required under C-3 Phase I

xxx

EO

xxx

3/1

Company

 

 

51

RBC Certification required under C-3 Phase II

xxx

EO

xxx

3/1

Company

 

 

52

Statement on non-guaranteed elements - Exhibit 5 Int. #3

1

EO

1

3/1

Company

 

 

53

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

1

EO

1

3/1

Company

 

 

 

 

 

 

 

 

 

 

 

 

III.  ELECTRONIC FILING   REQUIREMENTS

 

 

61

Annual Statement Electronic Filing

xxx

1

xxx

3/1

NAIC

 

 

62

March .PDF Filing

xxx

1

xxx

3/1

NAIC

 

 

63

Risk-Based Capital Electronic Filing

xxx

1

N/A

3/1

NAIC

 

 

64

Risk-Based Capital .PDF Filing

xxx

1

N/A

3/1

NAIC

 

 

65

Separate Accounts Electronic Filing

xxx

1

xxx

3/1

NAIC

 

 

66

Separate Accounts .PDF Filing

xxx

1

xxx

3/1

NAIC

 

 

67

Supplemental Electronic Filing

xxx

1

xxx

4/1

NAIC

 

 

68

Supplemental .PDF Filing

xxx

1

xxx

4/1

NAIC

 

 

69

Quarterly Statement Electronic Filing

xxx

1

xxx

5/15, 8/15,   11/15

NAIC

 

 

70

Quarterly .PDF Filing

xxx

1

xxx

5/15, 8/15,   11/15

NAIC

 

 

71

June .PDF Filing

xxx

1

xxx

5/31

NAIC

 

 

 

 

 

 

 

 

 

 

 

 

IV.  AUDIT/INTERNAL CONTROL RELATED REPORTS

 

 

81

Accountants Letter of Qualifications

1

EO

N/A

5/31

Company

See Note B

 

82

Audited Financial Reports

1

EO

1

5/31

Company

See Note B

 

83

Audited Financial Reports Exemption Affidavit

1

N/A

N/A

 

Company

See Note B

 

84

Communication of Internal Control Related Matters Noted in Audit

1

EO

1

5/31

Company

See Note B

 

85

Independent CPA (change)

1

N/A

N/A

Within 60 days of any change

Company

See Note B

 

86

Management’s Report of Internal Control Over Financial Reporting

1

N/A

1

5/31

Company

See Note B

 

87

Notification of Adverse Financial Condition

1

N/A

1

5/31

Company

See Note B

 

88

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

1

EO

1

3/1

Company

Call for instructions

 

89

Relief from the one-year cooling off period for independent CPA

1

EO

1

3/1

Company

Call for instructions

 

90

Relief from the Requirements for Audit Committees

0

EO

1

3/1

Company

Call for instructions

 

91

Request for Exemption to File Management’s Report of Internal Control Over Financial Reporting

1

N/A

1

 

Company

Call for instructions

 

 

 

 

 

 

 

 

 

 

 

V.  STATE REQUIRED FILINGS

 

 

101

Certificate of Compliance

0

0

1

 

State

See Note P

 

102

Certificate of Deposit

0

0

1

 

State

See Note Q

 

103

Electronic Filing New York Annual Supplement

1

N/A

1

3/1

State

 

 

104

Electronic Filing New York Quarterly Supplement

1

0

1

5/15,   8/15, 11/15

State

 

 

105

Filings Checklist (with Column 1 completed)

1

1

1

3/1

State

 

 

106

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

1

N/A

1

3/15

State

See Note S

 

107

Form B-Holding Company Registration   Statement

1

N/A

1

5/1

Company

See Note T

 

108

Form F-Enterprise Risk Report ***

1

N/A

1

4/30

Company

See Note U

 

109

New York Annual Supplement

1

N/A

1

3/1

State

 

 

110

New York Quarterly Supplement

1

N/A

1

5/15,   8/15, 11/15

State

 

 

111

ORSA ****

1

N/A

1

12/1

Company

See Note T

 

112

Signed Jurat

1

N/A

1

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

State

 

 

 

 

 

 

 

 

 

 

*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

****For those states that have adopted the NAIC updated Risk Management and Own Risk and Solvency Assessment Model Act, a summary report is required annually by insurers and insurance groups above a specified premium threshold. Consistent with the Form B filing requirements, the ORSA Summary Report 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)

  A Required Filings Contact Person:

 

Mr. Warren Youngs, Health Bureau
New York State Department of Financial Services
One State Street
New York, NY 10004
(212) 480-3883

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

  B Mailing 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

CDs (See Note O):

Mr. William Pow, Information Technology
New York State Department of Financial Services
One State Street
New York, NY 10004
  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. CDs 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: None 
  O Internet Filing:

Instructions concerning internet filing alternative to filing CD 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 61, 62, 63, 64, 65, 66, 67, 68, 69, 70 and 71 in the checklist) with the NAIC preferably via the Internet. By filing over the Internet or via CD with the NAIC an insurer will have fulfilled its electronic filing requirement for national forms with New York and therefore should not file a CD with the Department

  P Certificate of Compliance: Ms. Christine Gralton, Health Bureau
New York State Department of Financial Services
One State Street
New York, NY 10004
  Q Certificate of Deposit: Ms. Christine Gralton, Health Bureau
New York State Department of Financial Services
One State Street
New York, NY 10004
  R Certificate of Valuation: Ms. Christine Gralton, Health Bureau
New York State Department of Financial Services
One State 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
Office of Financial Management
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 CD with the NAIC. Companies that file with the NAIC via the Internet are not required to submit CDs 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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