NAIC and Department of Financial Services Annual Statement Checklist and Instructions
Life, Accident and Health/Fraternal Insurers 2024-2025
| COMPANY NAME: | NAIC Company Code: |
| Contact: | Telephone: |
| REQUIRED FILINGS IN THE STATE OF: NEW YORK | Filings Made During the Year 2025 |
FRATERNAL COMPANIES BEGIN FILING LIFE/FRATERNAL STATEMENT EFFECTIVE WITH FIRST QUARTER, 2019
| (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”) | EF*** | EO | EF*** | 3/1 | NAIC | ||
| 1.1 | Printed Investment Schedule detail (Pages E01-E29) | EF*** | EO | EF*** | 3/1 | NAIC | ||
| 2 | Quarterly Financial Statement (8 ½” x 14”) | EF*** | EO | EF*** | 5/15, 8/15, | NAIC | ||
| 3 | Separate Accounts Annual Statement (8 ½”x14”) | EF*** | EO | EF*** | 3/1 | NAIC | ||
| II. NAIC SUPPLEMENTS | ||||||||
| 11 | Accident & Health Policy Experience Exhibit | EF*** | EO | EF*** | 4/1 | NAIC | ||
| 12 | Credit Insurance Experience Exhibit | EF*** | EO | xxx | 4/1 | NAIC | ||
| 13 | Health Supplement | xxx | EO | xxx | 3/1 | |||
| 14 | Life, Health & Annuity Guaranty Association Assessable Premium Exhibit, Parts 1 and 2 | EF*** | EO | xxx | 4/1 | NAIC | ||
| 15 | Long Term Care Experience Reporting Forms | EF*** | EO | xxx | 4/1 | NAIC | ||
| 16 | Management Discussion & Analysis | EF*** | EO | EF*** | 4/1 | Company | ||
| 17 | Market Conduct Annual Statement Premium Exhibit for Year | N/A | EO | N/A | 3/1 | NAIC |
| |
| 18 | Medicare Supplement Insurance Experience Exhibit | EF*** | EO | xxx | 3/1 | NAIC | ||
| 19 | Medicare Part D Coverage Supplement | EF*** | EO | EF*** | 3/1, 5/15, 8/15, | NAIC | ||
| 20 | Risk-Based Capital Report | EF*** | EO | EF*** | 3/1 | NAIC | Note P | |
| 21 | Schedule SIS | 1 | N/A | N/A | 3/1 | NAIC | ||
| 22 | Supplemental Compensation Exhibit | 1 | N/A | N/A | 3/1 | NAIC | ||
| 23 | Supplemental Health Care Exhibit (Parts 1 and 2) | xxx | EO | xxx | 4/1 | NAIC | ||
| 24 | Supplemental Investment Risk Interrogatories | EF*** | EO | EF*** | 4/1 | NAIC | ||
| 25 | Supplemental Schedule O | EF*** | EO | xxx | 3/1 | NAIC | ||
| 26 | Supplemental Term and Universal Life Insurance Reinsurance Exhibit | EF*** | EO | EF*** | 4/1 | NAIC | ||
| 27 | Trusteed Surplus Statement (Aliens) | EF*** | EO | EF*** | 3/1, 5/15, 8/15, | NAIC | ||
| 28 | Variable Annuities Supplement | EF*** | EO | EF*** | 4/1 | NAIC | ||
| 29 | VM 20 Reserves Supplement | xxx | EO | xxx | 3/1 | NAIC | ||
| 30 | Workers’ Compensation Carve Out Supplement | EF*** | EO | EF*** | 3/1 | NAIC | ||
| Actuarial Related Items | ||||||||
| 31 | Actuarial Certification regarding use 2001 Preferred Class Table | xxx | EO | xxx | 3/1 | Company | ||
| 32 | Actuarial Certification Related Annuity Nonforfeiture Ongoing Compliance for Equity Indexed Annuities | xxx | EO | xxx | 3/1 | Company | ||
| 33 | Actuarial Memorandum Related to Universal Life with Secondary Guarantee Policies required by Actuarial Guideline XXXVIII 8D | xxx | N/A | xxx | 4/30 | Company | ||
| 34 | Actuarial Opinion | 1 | EO | 1 | 3/1 | Company | Note Q | |
| 35 | Actuarial Opinion on Separate Accounts Funding Guaranteed Minimum Benefit | xxx | EO | xxx | 3/1 | Company | ||
| 36 | Actuarial Opinion on Synthetic Guaranteed Investment Contracts | xxx | EO | xxx | 3/1 | Company | ||
| 37 | Actuarial Opinion on X-Factors | xxx | EO | xxx | 3/1 | Company | ||
| 38 | Actuarial Opinion required by Modified Guaranteed Annuity Model Regulation | xxx | EO | xxx | 3/1 | Company | ||
| 39 | Request for Life PBR Exemption if applicable) | 1 | EO | xxx | Commissioner | Company | ||
| 40 | Executive Summary of the PBR Actuarial Report | xxx | N/A | xxx | 4/1 | Company | ||
| 41 | Life Summary of the PBR Actuarial Report | xxx | N/A | xxx | 4/1 | Company | ||
| 42 | Variable Annuities Summary of the PBR Actuarial Report | xxx | N/A | xxx | 4/1 | Company | ||
| 43 | PBR Actuarial Report (provide upon request) | N/A | Company | |||||
| 44 | RAAIS required by Valuation Manual | 1 | N/A | 1 | 4/1 | Company | Note Q | |
| 45 | Reasonableness & Consistency of Assumptions Certification required by Actuarial Guideline XXXV | xxx | EO | xxx | 3/1, 5/15, 8/15, | Company | ||
| 46 | Reasonableness of Assumptions Certification required by Actuarial Guideline XXXV | xxx | EO | xxx | 3/1, 5/15, 8/15, | 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, | Company | ||
| 48 | Reasonableness & Consistency of Assumptions Certification required by Actuarial Guideline XXXVI (Updated Market Value) | xxx | EO | xxx | 3/1, 5/15, 8/15, | 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, | 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 | Note U | |
| 53 | Statement on par/non-par policies – Exhibit 5 Int. 1&2 | 1 | EO | 1 | 3/1 | Company | Note U | |
| 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 | N/A | 3/1 | NAIC | ||
| 64 | Risk-Based Capital .PDF Filing | xxx | EO | N/A | 3/1 | NAIC | ||
| 65 | Separate Accounts Electronic Filing | xxx | EO | xxx | 3/1 | NAIC | ||
| 66 | Separate Accounts .PDF Filing | xxx | EO | xxx | 3/1 | NAIC | ||
| 67 | Supplemental Electronic Filing | xxx | EO | xxx | 4/1 | NAIC | ||
| 68 | Supplemental .PDF Filing | xxx | EO | xxx | 4/1 | NAIC | ||
| 69 | Quarterly Electronic Filing | xxx | EO | xxx | 5/15, 8/15, 11/15 | NAIC | ||
| 70 | Quarterly .PDF Filing | xxx | EO | xxx | 5/15, 8/15, 11/15 | NAIC | ||
| 71 | June .PDF Filing | xxx | EO | xxx | 5/31 | NAIC | ||
| IV. AUDIT/INTERNAL CONTROL RELATED REPORTS | ||||||||
| 81 | Accountants Letter of Qualifications | EF*** | EO | N/A | 5/31 | Company | ||
| 82 | Audited Financial Statements & CPA Report on Internal Controls | EF*** | EO | EF*** | 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 | EF*** | EO | EF*** | 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 | 1 | 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 | EF*** | N/A | EF*** | 3/1 | State | ||
| 102 | Electronic Filing New York Supplement | EF*** | N/A | EF*** | 3/1 | State | ||
| 103 | Signed and Notarized Jurat (Annual NAIC Blank) | 1 | 0 | 1 | 3/1 | NAIC | Note G, H | |
| 103a | Signed and Notarized Jurat (New York Supplement) | 1 | 0 | 1 | 3/1 | State | Note G, H | |
| 103b | Signed and Notarized Jurat (Quarterly) | 1 | 0 | 1 | 5/15, 8/15, 11/15 | NAIC | Note G, H | |
| 104 | Certificate of Compliance (Regulation 74) | 1 | 0 | 1 | 3/1 | State | Note U | |
| 105 | Corporate Governance Annual Disclosure**** | 1 | 0 | 1 | 6/1 | Company | Note V | |
| 106 | Form B-Holding Company Registration Statement | 1 | 0 | 1 | 5/1 | Company | Note V | |
| 107 | Form F-Enterprise Risk Report ***** | 1 | 0 | 1 | 4/30 | Company | Note V | |
| 108 | ORSA****** | 1 | 0 | 0 | 12/1 | Company | Note V | |
| 109 | Group Capital Calculation (File with lead state only) | 1 | 0 | 0 | 6/30 | Company | Note V | |
| 110 | Cybersecurity Certification of Compliance | 1 | 0 | 1 | 4/15 | Company | Note W | |
| 111 | Corporation Franchise Tax to Dept. of Taxation (Copy to Department of Financial Services) | 1 | N/A | 1 | 4/15 | 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.
***If EF appears in this column, electronic filings (“EF”) to the NAIC are equivalent to filing with DFS. The Department reserves the right to request hard copies.
****The Corporate Governance Annual Disclosure is required to be filed annually by authorized insurers. 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).
*****A Form F filing is required to be filed annually by a New York domestic insurer 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 insurer 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) on the NYCRR.
******An ORSA Summary Report is required to be filed by a New York domestic insurer that meets a specified premium threshold and/or where the New York domestic insurer 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) on the NYCRR.
| Note | Notes and Instructions | (A-W apply to all filings) |
|---|---|---|
| A | Required Filings Contact Person: | Mr. Stephen Pallas, Life 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 payments with the Annual Statement (See Note R below). |
| E | Delivery Instructions: | All Department filings must be filed electronically no later than the indicated due date. Insurers are not required to submit a hard copy of the electronic filing unless requested by the Department. 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 Section 307 and 308. |
| G | Signatures/Notarization: | “Wet” or electronic signatures are required. Appropriate notarization required on the actual document. |
| H | Filing of Signed and Notarized Jurat pages: | Insurers are required to file a PDF copy of the fully executed and notarized Jurat pages of the Annual and Quarterly filings, specifically lines 103, 103(a) and 103(b) of the checklist above, directly with this Department via the Department’s Insurance Company and Fraternal Benefit Filing Portal. |
| I | Amended Filings: | Only accepted in accordance with Department of Financial Services’ prior instructions. All amendments to your Annual and Quarterly Statements are required to be filed electronically with the NAIC. Note: For Amended New York Supplement filings, the entire electronic filing is required to be filed with the NAIC. |
| J | Exceptions from normal filings: | Only accepted in accordance with Department of Financial Services’ prior instructions. |
| K | Bar Codes (State or 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 NY Supplement. |
| 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: | Investment schedules required for all filings. |
| N | Filings new, discontinued or modified materially since last year: | Please review checklist for the changes made this year. |
| O | Internet Filing: | Companies are strongly encouraged to file all annual and quarterly statement filings electronically with the NAIC. Instructions on filing over the Internet with the NAIC are available on their Web site at http://www.naic.org/. By filing electronically with the NAIC, an insurer will have fulfilled its filing requirement for national forms with New York. |
| P | Risk-Based Capital Report: | Electronic filing to the NAIC is equivalent to filing with DFS. |
| Q | Actuarial Opinion and RAAIS: | [email protected] or 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 Please note: Any payment due with the CT-33 should be sent to: |
| S | Audited Financial Statements | Electronic filing to the NAIC is equivalent to filing with DFS. |
| T | Independent CPA Assessment of Internal Controls Relative to Derivatives (where applicable) | Mr. Victor Agbu, Life Bureau New York State Department of Financial Services One State Street New York, NY 10004 |
| U | Certificate of Compliance (Regulation 74) Statement on non‐guaranteed elements ‐ Exhibit 5 Int. #3 Statement on par/non‐par policies – Exhibit 5 Int. 1&2 | File via SERFF as Type of Insurance (TOI) "Life Insurance & Annuity Products", SubTOI "General", Filing types "Regulation 74 Certificate of Compliance" “Statement on non‐guaranteed elements, Exhibit 5 Int. #3" "Statement on par/non‐par policies, Exhibit 5 Int. 1&2" |
| V | Holding Company Registration Statement, Corporate Governance Annual Disclosure, Enterprise Risk Report, ORSA and Group Capital Calculation. | Submit electronically through the Department’s Insurance Company and Fraternal Benefit Society Filings portal. |
| W | Cybersecurity Certificate of Compliance | File electronically through the Department’s Cybersecurity 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 include filing via the Internet or 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 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 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. 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. 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.