NAIC and Department of Financial Services Annual Statement Checklist and Instructions
Accident and Health Insurers Filing Blank 2024-2025
| COMPANY NAME: | NAIC Company Code: |
| Contact: | Telephone: |
| REQUIRED FILINGS IN THE STATE OF: NEW YORK | Filings Made During the Year 2025 |
| (1) Checklist | (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”) | EF****** | EO | EF****** | 3/1 | NAIC | Note E | |
| 1.1 | Printed Investment Schedule detail (Pages E01-E29) | EF****** | EO | EF****** | 3/1 | NAIC | Note E | |
| 2 | Quarterly Financial Statement (8 ½” x 14”) | EF****** | EO | EF****** | 5/15, 8/15, 11/15 | NAIC | Note E | |
| II. NAIC SUPPLEMENTS | ||||||||
| 11 | Accident & Health Policy Experience Exhibit | EF****** | EO | EF****** | 4/1 | NAIC | ||
| 12 | Actuarial Opinion | EF****** | EO | EF****** | 3/1 | Company | ||
| 13 | Life Supplemental Data due March 1 | xxx | EO | xxx | 3/1 | NAIC | ||
| 14 | Life Supplemental Data due April 1 | xxx | EO | xxx | 4/1 | NAIC | ||
| 15 | Life Supp Statement non-guaranteed elements – Exh 5, Int. #3 | xxx | EO | xxx | 3/1 | Company | ||
| 16 | Life Supp Statement on par/non-par policies – Exh 5 Int. 1&2 | xxx | EO | xxx | 3/1 | Company | ||
| 17 | Life, Health & Annuity Guaranty Association Assessable Premium Exhibit, Parts 1 and 2 | EF****** | EO | EF****** | 4/1 | NAIC | ||
| 18 | Long-Term Care Experience Reporting Forms | EF****** | EO | xxx | 4/1 | NAIC | ||
| 19 | Management Discussion & Analysis | EF****** | EO | EF****** | 4/1 | Company | ||
| 21 | Medicare Part D Coverage Supplement | EF****** | EO | EF****** | 3/1, 5/15, 8/15,11/15 | NAIC | ||
| 22 | Medicare Supplement Insurance Experience Exhibit | EF****** | EO | xxx | 3/1 | NAIC | ||
| 23 | Risk-Based Capital Report | EF****** | EO | EF****** | 3/1 | NAIC | ||
| 24 | Schedule SIS | EF****** | N/A | xxx | 3/1 | NAIC | ||
| 25 | Supplemental Compensation Exhibit | 1 | N/A | EF****** | 3/1 | NAIC | Note W | |
| 26 | Supplemental Health Care Exhibit (Parts 1 and 2) | EF****** | EO | EF****** | 4/1 | NAIC | ||
| 27 | Supplemental Investment Risk Interrogatories | EF****** | EO | EF****** | 4/1 | NAIC | ||
| III. ELECTRONIC FILING REQUIREMENTS | ||||||||
| 61 | Annual Statement Electronic Filing | xxx | EO | xxx | 3/1 | NAIC | ||
| 62 | March .PDF Filing | xxx | EO | xxx | 3/1 | NAIC | ||
| 63 | Risk-Based Capital Electronic Filing | xxx | EO | xxx | 3/1 | NAIC | ||
| 64 | Risk-Based Capital .PDF Filing | xxx | EO | xxx | 3/1 | NAIC | ||
| 65 | Supplemental Electronic Filing | xxx | EO | xxx | 4/1 | NAIC | ||
| 66 | Supplemental .PDF Filing | xxx | EO | xxx | 4/1 | NAIC | ||
| 67 | Quarterly Statement Electronic Filing | xxx | EO | xxx | 5/15, 8/15, 11/15 | NAIC | ||
| 68 | Quarterly .PDF Filing | xxx | EO | xxx | 5/15, 8/15, 11/15 | NAIC | ||
| 69 | June .PDF Filing | xxx | EO | xxx | 5/31 | NAIC | ||
| IV. AUDIT/INTERNAL CONTROL RELATED REPORTS | ||||||||
| 81 | Accountants Letter of Qualifications (11 NYCRR 89.10) | EF****** | EO | N/A | 5/31 | Company |
| |
| 82 | Audited Financial Reports | EF****** | EO | EF****** | 5/31 | Company | Note E | |
| 83 | Audited Financial Reports Exemption Affidavit | EF****** | N/A | N/A | 5/31 | Company | Note W | |
| 84 | Communication of Internal Control Related Matters Noted in Audit (11 NYCRR 89.9) | EF****** | EO | EF****** | 5/31 | Company | Note X | |
| 85 | Independent CPA (change) (11 NYCRR 89.4) | EF****** | N/A | N/A | Within 60 days of any change | Company | Note Y | |
| 86 | Management’s Report of Internal Control Over Financial Reporting (11 NYCRR 89.14) | EF****** | N/A | EF****** | 5/31 | Company | Note W | |
| 87 | Notification of Adverse Financial Condition (11 NYCRR 89.8) | EF****** | N/A | EF****** | Within 5 business days of the determination | Company | Note W | |
| 88 | Relief from the five-year rotation requirement for lead audit partner (11 NYCRR89.5(c) | EF****** | EO | EF****** | 3/1 | Company | Note W | |
| 89 | Relief from the one-year cooling off period for independent CPA (11 NYCRR 89,5(j)) | EF****** | EO | EF****** | 3/1 | Company | Note W | |
| 90 | Relief from the Requirements for Audit Committees | EF****** | EO | EF****** | 3/1 | Company | Note W | |
| 91 | Hardship Exemption | EF****** | N/A | EF****** | 3/1 | Company | Note W | |
| 92 | Change in the Membership of the Audit Committee (11 NYCRR 89.12(e)) | EF****** | N/A | EF****** | Within 30 days of any change | Company | Note W | |
| V. STATE REQUIRED FILINGS | ||||||||
| 102 | Certificate of Deposit | 0 | N/A | EF****** | State | Note Q | ||
| 103(a) | Signed and Notarized Jurat Page (Annual NAIC Blank) | EF****** | N/A | EF****** | 3/1 | NAIC | Notes G, H, L | |
| 103(b) | Signed and Notarized Jurat Page (Annual New York Supplement) | EF****** | N/A | EF****** | 3/1 | State | Notes G, H, L | |
| 103(c) | Signed and Notarized Jurat Page (Quarterly NAIC Blank) | EF****** | N/A | EF****** | 5/15, 8/15, 11/15 | NAIC | Notes G, H, L | |
| 103(d) | Signed and Notarized Jurat Page (Quarterly New York Supplement) | EF****** | N/A | EF****** | 5/15, 8/15, 11/15 | State | Notes G, H, L | |
| 104 | Signed and Notarized Certificate of Compliance with the advertising requirements of Regulation 34 (11 NYCRR 215) (Annual New York Supplement Exhibit) | EF****** | N/A | EF****** | 3/1 | State | Notes G, H, L | |
| 105 | Filings Checklist (with Column 1 completed) | EF****** | N/A | EF****** | 3/1 | State | Note L | |
| 106 | Form B-Holding Company Registration Statement | EF****** | N/A | EF****** | 4/30 | Company | Note T | |
| 107 | Form F-Enterprise Risk Report *** | EF****** | N/A | EF****** | 4/30 | Company | Note T | |
| 108 | New York Annual Supplement | EF****** | N/A | EF****** | 3/1 | State | Note E | |
| 109 | New York Quarterly Supplement | EF****** | N/A | EF****** | 5/15, 8/15, 11/15 | State | Note E | |
| 110 | ORSA Electronic Filing **** | EF****** | N/A | 0 | 12/1 | Company | Note T | |
| 111 | Premium Tax | EF****** | N/A | EF****** | State | Notes D, S | ||
| 112 | Qualifications of CPA – Section 89.5(e)(2) of DFS Insurance Regulation 118 | EF****** | N/A | EF****** | 5/31 | Company | Note U | |
| 113 | Change in Actuary | EF****** | N/A | EF****** | Within 5 days of any change | Company | Note Y | |
| 114 | Corporate Governance Annual Disclosure***** | EF****** | N/A | EF****** | 6/1 | Company | Note T | |
| 115 | Attestation on Segregation of Funds – Circular Letter #7 (2013) | EF****** | N/A | EF****** | 3/1 | Company | Note V | |
| 116 | Group Capital Calculation (File with lead state only) | EF****** | N/A | EF****** | 6/30 | Note T | ||
| 117 | Cybersecurity Certificate of Compliance | EF****** | N/A | EF****** | 4/15 | Company | Note Z | |
| 118 | Copy of the minutes of the Annual Meeting of the Board of Directors of the filing entity | EF****** | N/A | EF****** | 3/1 | Company | Note W | |
* If XXX appears in this column, this state does not require this filing, providing 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, visit the NAIC website.
****For those states that have adopted the NAIC 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. 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 if filed at the insurance group level. For more information on lead states, visit the NAIC website.
***** For those states that have adopted the NAIC Corporate Governance Annual Disclosure Model Act, an annual disclosure is required of all insurers or insurance groups by June 1. The Corporate Governance Annual Disclosure 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 if filed at the insurance group level. For more information on lead states, visit the NAIC website.
****** If EF appears in this column, electronic filings (“EF”) to the NAIC are equivalent to filing with DFS.
NOTES AND INSTRUCTIONS (A-Z APPLY TO ALL FILINGS)
| A | Required Filings Contact Person: | Mr. Ergys Shanaj, Health Bureau When answering by e-mail, please include telephone number. |
| B | Mailing Address: | N/A |
| C | Mailing Address for Filing Fees: | N/A |
| D | Mailing Address for Premium Tax Payments: | Do not include payment with the Annual Statement. See Note S. |
| E | Delivery Instructions: | All Department of Financial Services filings must be filed electronically no later than the indicated due date. Companies are not required to submit hard copies of their electronic filings unless requested by the Department. In addition to the electronic filing to the NAIC, all companies are also required to file PDF copies of the fully executed Jurat pages and Certification of Compliance etc. of the Annual and Quarterly filings directly with this Department via the Department's insurance entity filings portal: If the due date falls on a weekend or a legal holiday, then the filing must be submitted by the end of the next business day. |
| 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 Sections 307 and 308. New York statute does not provide for any extensions in the filing deadlines for Annual Statements. Further, extensions for the filing of audited financial statements are only provided upon written application by the company to the Superintendent, and such extension is only granted if the Superintendent finds that compliance would constitute a financial or organizational hardship, as provided in Section 307(b)(3) of the Insurance Law. |
| G | Original Signatures: | “Wet” or electronic signatures are required. See Note Q for further instructions. |
| H | Notarization: | Appropriate notarization required. See Note Q for further instructions. |
| I | Amended Filings: | Companies must obtain the Department’s prior approval before submitting any amended statements. All amendments to the Annual and Quarterly Statements and/or New York Supplement are required to be filed electronically with the NAIC. 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 approval. |
| K | Bar Codes (NAIC) | The NAIC Annual Statement requires the use of bar codes on the Jurat page and certain other pages and forms. Bar coding is no longer required for the New York Supplement. |
| L | Signed and Notarized Jurat pages and Certificate of Compliance Filing, and Filings checklist: | Insurers are required to file a PDF copy of the fully executed and notarized Jurat pages and Certificate of Compliance etc. of the Annual and Quarterly filings, especially lines s 103(a), 103(b), 103(c), 103(d), 104 and 105 of the checklist above, directly with this Department via the Department's insurance entity filings portal: https://www.dfs.ny.gov/apps_and_licensing/insurance_companies/insco_fratbenesoc_filings; under the appropriate “Other” category. |
| M | NONE Filings: | All parts of the Annual Statement except those schedules identified as "N/A" 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." |
| N | Investment Schedules: | Investment Schedules required for all filings. |
| O | Filings new, discontinued or modified materially since last year: | Instructions will be provided by the Department as needed. |
| P | Internet Filing: | Instructions concerning internet filing alternative to filing CD with New York for New York Supplement are set forth in Insurance Circular Letter No. 4 (2001) All companies must file national form filings (as identified in items 61, 62, 63, 64, 65, 66, 67, 68 and 69 in the checklist) with the NAIC preferably via the Internet. By filing over the Internet with the NAIC an insurer will have fulfilled its electronic filing requirement for national forms with New York. |
| Q | Certificate of Deposit: | Companies are required to file electronically through the Department’s insurance entity filings portal: https://www.dfs.ny.gov/apps_and_licensing/insurance_companies/insco_fratbenesoc_filings under the appropriate category. |
| R | Certificate of Valuation: | Companies are required to file electronically through the Department’s insurance entity filings portal: https://www.dfs.ny.gov/apps_and_licensing/insurance_companies/insco_fratbenesoc_filings under the appropriate category. |
| 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 Please note: Any payment due with the CT-33 should be sent to: NYS Department of Taxation and Finance |
| T | Holding Company and Parent Corporation Filings Form HC-1, and Form IR Electronic Filings, Corporate Governance Annual Disclosure, Form F Enterprise Risk Management, Own Risk and Solvency Assessment (ORSA), Group Capital Calculation | Companies are required to file ORSA, Group Capital Calculation, and Form F through the Department’s insurance entity filings portal: (“the Portal”). Furthermore, companies are strongly encouraged to file Corporate Governance Annual Disclosure, Form HC-1, and Form IR through the Portal as well. https://www.dfs.ny.gov/apps_and_licensing/insurance_companies/insco_fratbenesoc_filings An ORSA Summary Report is required to be filed annually by a New York domestic company that meets a specified premium threshold and/or where the New York domestic company is a member of a group that meets a specified premium threshold. The ORSA Summary Report is a state filing only and should not be submitted by the company to the NAIC. For more information, please refer to Regulation 203 (11 NYCRR 82). A Form F filing is required to be filed annually by a New York domestic company that is not part of a group and meets a specified premium threshold. For groups, it must be filed by the ultimate holding company for an Article 15 group and by the parent domestic company in an Article 17 group. 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. For more information, please refer to Regulation 203 (11 NYCRR 82). The Corporate Governance Annual Disclosure is required to be filed annually by authorized companies. The Corporate Governance Annual Disclosure is a state filing only and should not be submitted by the company to the NAIC. For more information, please refer to Regulation 215 (11 NYCRR 90). |
| U | Qualifications of CPA – Section 89.5(e)(2) of DFS Insurance Regulation 118 | Pursuant to Section 89.5(e)(2) of Insurance Regulation 118: “The company shall attach a statement to its audited annual financial statement, when filed, that the CPA does not function in the role of management, does not audit his or her own work, and does not serve in an advocacy role for company.” |
| V | Attestation to Segregation of Funds | Under the United States Department of Health and Human Services (“HHS”) regulation a Qualified Health Plan (“QHP”) issuer must file an annual assurance with the Superintendent attesting that the QHP issuer has complied with 42 USC §18023 and all applicable regulations. The company may file through the Department’s insurance entity filings portal noted in Note X. |
| W | The filings identified in Lines 25, 83, 86, 87, 88, 89, 90, 91, 92 and 118 | Companies are required to file electronically through the Department’s insurance entity filings portal: https://www.dfs.ny.gov/apps_and_licensing/insurance_companies/insco_fratbenesoc_filings Companies must file, with its annual statement filing, by the indicated due date, both its request for relief and the domiciliary state’s approval of that request with the New York State Department of Financial Services and the NAIC. Lines 88 through 91: New York domestic company wishing to apply for the New York State Department of Financial Services (DFS)’s approval of the indicated relief must do so in accordance with the requirements set forth in New York Regulation No. 118 (11 NYCRR 89) and/or NYIL 307. Line 88: The application for relief from the rotation requirement (line 88) must be made to DFS via the Department’s Filing Portal above at least 30 days before the end of the calendar year. Line 91: Any application for exemption to file pursuant to New York Insurance Regulation 118 (11 NYCRR 89) and/or NYIL 307 must be filed with the Superintendent through the Department’s Filing Portal above prior to the event or period for which the exemption is being requested. Line 92: Companies must provide written notice within 30 days of any change in membership of the audit committee. The notice shall include a description of the reason for the change. |
| X | Independent CPA (change) | Provide updated information (name, address, telephone number and e-mail address of the new CPA) within 60 days of any change in CPA. The company shall obtain a letter from the CPA, and file a copy with the Superintendent, stating that the CPA is aware of the provisions of the insurance law and the regulations thereunder of the state of domicile that relate to accounting and financial matters and affirming that the CPA will express his or her opinion on the financial statements in terms of their conformity to the statutory accounting practices prescribed or otherwise permitted by that insurance department, specifying such exceptions as the CPA may believe appropriate. In addition, Companies must comply with the reporting requirements of Regulation 118, Section 89.4(c) in an event that its CPA is dismissed or resigns. File electronically through the Department’s insurance entity filings portal: |
| Y | Change in Actuary | If there is a change in actuary, the Company shall notify the New York State Department of Financial Services within five business days of the event in accordance with the NAIC Annual Statement Instructions. File electronically through the Department’s insurance entity filings portal: |
| Z | Cybersecurity Certificate of Compliance | File electronically through the Department’s Cybersecurity Portal: https://myportal.dfs.ny.gov/ |
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 send their own checklist .
Electronic Filing is intended to be filing(s) submitted to the NAIC via the NAIC website which eliminates the need for a company to submit disks 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 submitting 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 Supplemental.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 file for quarterly statement data.
The June.PDF Filing is the .pdf file for the Audited Financial Statements and Accountants Letter of Qualifications.
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 (EX) 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 (EX) 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 the state 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.