NAIC and Department of Financial Services Annual Statement Checklist and Instructions

ACCIDENT AND HEALTH INSURERS FILING ON THE HEALTH BLANK 2021-2022

COMPANY NAME:

NAIC Company Code:

Contact:

Telephone:

REQUIRED FILINGS IN THE STATE OF: NEW YORK 

Filings Made During the Year 2022

 

(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”)

1

EO

1

3/1

NAIC

Notes B & W

 

1.1

Printed Investment Schedule detail (Pages E01-E29)

1

EO

1

3/1

NAIC

Note B

 

2

Quarterly Financial Statement (8 ½” x 14”)

1

EO

1

5/15, 8/15, 11/15

NAIC

Notes B & W

 

 

 

 

 

 

 

 

 

 

 

II. NAIC SUPPLEMENTS

 

 

11

Accident & Health Policy Experience Exhibit

1

EO

1

4/1

NAIC

 

 

12

Actuarial Opinion

1

EO

1

3/1

Company

Note B

 

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

1

EO

1

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 Part D Coverage Supplement

1

EO

1

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

NAIC

 

 

21

Medicare Supplement Insurance Experience Exhibit

1

EO

xxx

3/1

NAIC

 

 

22

Risk-Based Capital Report

1

EO

1

3/1

NAIC

 

 

23

Schedule SIS

1

0

xxx

3/1

NAIC

 

 

24

Supplemental Compensation Exhibit

1

0

1

3/1

NAIC

 

 

25

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

1

EO

1

4/1

NAIC

 

 

26

Supplemental Health Care Exhibit’s Allocation Report

1

EO

1

4/1

NAIC

 

 

27

Supplemental Investment Risk Interrogatories

1

EO

1

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

1

EO

N/A

5/31

Company

Note B

 

82

Audited Financial Reports

1

EO

1

5/31

Company

Note B

 

83

Audited Financial Reports Exemption Affidavit

1

N/A

N/A

 

Company

Note B

 

84

Communication of Internal Control Related Matters Noted in Audit

1

EO

1

5/31

Company

Note B

 

85

Independent CPA (change)

1

N/A

N/A

Within 60 days of any change

Company

Note B

 

86

Management’s Report of Internal Control Over Financial Reporting

1

N/A

1

5/31

Company

Note B

 

87

Notification of Adverse Financial Condition

1

N/A

1

5/31

Company

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

1

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

Note P

 

102

Certificate of Deposit

0

0

1

 

State

Note Q

 

103

Electronic Filing New York Annual Supplement

1

0

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

0

1

3/1

State

 

 

106

Form B-Holding Company Registration Statement

1

0

1

4/30

Company

Note U

 

107

Form F-Enterprise Risk Report ***

1

0

1

4/30

Company

Note T

 

108

New York Annual Supplement

1

0

1

3/1

State

Notes B & W

 

109

New York Quarterly Supplement

1

0

1

5/15, 8/15, 11/15

State

Notes B & W

 

110

ORSA ****

1

0

0

12/1

Company

Note T

 

111

Premium Tax

1

0

1

 

State

 

 

112

State Filing Fees

0

0

0

 

State

 

 

113

Qualifications of CPA – Section 89.5(e)(2) of DFS Insurance Regulation 118

1

0

1

5/31

Company

Note V

 

114

Change in Actuary

1

0

1

Within 5 days of any change

Company

Note B

 

115

Corporate Governance Annual Disclosure

1

0

1

6/1

Company

Note T

 

116

Attestation on Segregation of Funds – Circular Letter #7 (2013)

1

0

1

3/1

Company

Note X

*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 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, 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: [email protected]

When answering by e-mail, please include telephone number.

B

Mailing Address:

Annual Statement and New York Supplement, and related items (hard copies):
Mr. Thomas Dudek, Health Bureau
New York State Department of Financial Services
One State Street
New York, NY 10004

Audited Annual Statements and Risk Based Capital Report:
Mr. Thomas Dudek, Health Bureau
New York State Department of Financial Services
One State Street
New York, NY 10004

Quarterly Statement (hard copies):
Mr. Thomas Dudek, Health Bureau
New York State Department of Financial Services
One State Street
New York, NY 10004

Change in Actuary
Mr. Thomas Dudek, Health Bureau
New York State Department of Financial Services
One State Street
New York, NY 10004

CDs (See Note O):
Ms. Nikki Brate
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 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 Sections 307 and 308.

G

Original Signatures:

  1. Actual live signatures required. Please see Note W:

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:

N/A

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 and 69 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:

Mr. Thomas Dudek, Health Bureau
New York State Department of Financial Services
One State Street
New York, NY 10004

Q

Certificate of Deposit:

Mr. Thomas Dudek, Health Bureau
New York State Department of Financial Services
One State Street
New York, NY 10004

R

Certificate of Valuation:

Mr. Thomas Dudek, 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

T

Enterprise Risk Management and Own Risk and Solvency Assessment

Corporate Governance Annual Disclosure

Submit electronically through the Department’s Holding Company and Parent Corporation Filing Portal. Please follow the instructions at:

https://www.dfs.ny.gov/apps_and_licensing/insurance_companies/enter prise_risk_and_orsa

Hard copies see Note B

U

Holding Company and Parent Corporation Filings

Submit electronically through the Department’s Holding Company and Parent Corporation Filing Portal. Please follow the instructions at:

https://www.dfs.ny.gov/apps_and_licensing/insurance_companies/insco
_fratbenesoc_filings

Hard copies see Note B

V

Qualifications of CPA –
Section 89.5(e)(2) of DFS 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.

W

Current Guidance Regarding Electronic Signatures, Transactions, and Filings with DFS

COVID-19 pandemic guidance regarding electronic signatures, transactions, and filings with DFS

https://www.dfs.ny.gov/industry_guidance/electronic_signatures_transactions_filings

X

Attestation to Segregation of Funds

Circular Letter No. 7 (2013): Segregation of Funds for Certain Abortion Services on the Exchange for Enrollees who Receive Federal Funds | Department of Financial Services

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 Filings Portal described in Note T or email a copy to Health Bureau mailbox at HealthBureauRegulat[email protected] if the company has no access to the portal.


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 be filing(s) submitted to the NAIC via the NAIC Internet Filing Site which eliminates the need for a company to submit diskettes or CD-ROM 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.