Skip to Content

NAIC & Department of Financial Services Annual Statement Checklist and Instructions

LIFE, ACCIDENT AND HEALTH INSURERS 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 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   
                 
   

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  Note P 
  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 Certifications 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 Note Q
  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  Note Q
  45 Reasonableness & Consistency of Assumptions Certification required by Actuarial Guideline XXXV

xxx

EO 

xxx 

5/15, 8/15, 11/15 Company  
  46 Reasonableness of Assumptions Certification required by Actuarial Guideline XXXV

xxx

EO 

xxx

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 

5/15, 8/15, 11/15 Company  
  48 Reasonableness & Consistency of Assumptions Certification required by Actuarial Guideline XXXVI (Updated Market Value)

xxx

EO 

xxx 

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

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 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. AUDITED/INTERNAL CONTROL RELATED REPORTS 

           
  81  Accountants Letter of Qualifications 

1 

EO 

N/A 

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

1 

EO 

1 

5/31  Company  Note S 
  83  Audited Financial Statements Exemption Affidavit 

1 

N/A 

N/A 

5/31  Company   
  84  Communication of Internal Control Related Matters Noted in Audit 1 EO 1 5/31  Company   
  85 Independent CPA (change)

1 

N/A 

N/A 

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

1 

N/A 

1 

5/31  Company   
  88 Relief from the five-year rotation requirement for lead audit partner

1 

EO

1 

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

1 

EO

1

3/1 Company   
  90 Relief from the Requirements for Audit Committees

0 

EO

1 

3/1  Company   
  91 Request for Exemption to File Management’s Report of Internal Control Over Financial Reporting

1 

N/A 

N/A 

5/31  Company   
  92 Independent CPA Assessment of Internal Controls Relative to Derivatives (where applicable) 

1 

N/A 

1

5/31  Company  Note T 
                 
   

V. STATE REQUIRED FILINGS 

           
  101  New York Supplement 

1 

N/A 

1 

3/1  State   
  102  Electronic Filing New York Supplement 

1 

N/A 

1 

3/1  State   
  103  Certificate of Compliance 

0 

0 

0 

  State   
  104  Certificate of Deposit 

0 

0 

0 

  State   
  105  Certificate of Valuation 

0 

0 

1 

  State  Note Q 
  106  Filings Checklist (with Column 1 completed) 

1 

0 

1 

  State   
  107  Form   B-Holding Company Registration Statement

1 

0 

1 

5/1 Company    
  108  Form F-Enterprise Risk   Report ***

1 

0 

1 

4/30 Company   
  109  ORSA****

1 

0 

1 

12/1 Company   
  110 Corporation Franchise Tax to Dept. Of Taxation (Copy to Department of Financial Services) 

1 

N/A 

1 

3/15  State  Note R 

*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-T Apply to All Filings)

  A  Required 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. 

  B  Mailing Address:

 

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

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

QUARTERLY STATEMENT (Hard copies):

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

CDs (See Note O):

Mr. William Pow
Information Technology Systems
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 R 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. 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. 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 Website. 
  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 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:   
  O  Internet Filing:  Instructions concerning internet filing alternative to filing CDs 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 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  Risk-Based Capital Report: 

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

  Q  Certificate of Valuation, Actuarial Opinion and RAAIS:

Ms. Jennifer Savage, Life Bureau
New York State Department of Financial Services
One Commerce Plaza
Albany, NY 12257

  R  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, 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

  S  Audited Financial Statements 

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

  T  Independent 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 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 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 all investment schedule detail.

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 (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.

 

 HOME |   RETURN TO MAIN PAGERETURN TO INSURER PAGENAIC

 

Link to DFS Portal

About DFS

Contact DFS

Reports & Publications

Licensing

Laws and Regs

Connect With DFS

DFS Facebook page

Follow NYDFS on Twitter