NAIC and Department of Financial Services Annual Statement Checklist and Instructions

LIFE, ACCIDENT AND HEALTH / FRATERNAL INSURERS 2021-2022

COMPANY NAME: NAIC Company Code:
Contact: Telephone:
REQUIRED FILINGS IN THE STATE OF: NEW YORK Filings Made During the Year 2022

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”)

1

EO

1

3/1

NAIC

 

 

1.1

Printed Investment Schedule detail (Pages E01-E29)

1

EO

1

3/1

NAIC

 

 

2

Quarterly Financial Statement (8 ½” x 14”)

1

EO

1

5/15, 8/15,
11/15

NAIC

 

 

3

Separate Accounts Annual Statement (8 ½”x14”)

1

EO

1

3/1

NAIC

 

 

 

II. NAIC SUPPLEMENTS

 

 

11

Accident & Health Policy Experience Exhibit

1

EO

1

4/1

NAIC

 

 

12

Credit Insurance Experience Exhibit

1

EO

xxx

4/1

NAIC

 

 

13

Health Care Receivables Supplement

xxx

EO

xxx

3/1

 

 

 

14

Life, Health & Annuity Guaranty Association Assessable Premium Exhibit, Parts 1 and 2

1

EO

xxx

4/1

NAIC

 

 

15

Long Term Care Experience Reporting Forms

1

EO

xxx

4/1

NAIC

 

 

16

Management Discussion & Analysis

1

EO

1

4/1

Company

 

 

17

Medicare Supplement Insurance Experience Exhibit

1

EO

xxx

3/1

NAIC

 

 

18

Medicare Part D Coverage Supplement

1

EO

1

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

NAIC

 

 

19

Risk-Based Capital Report

1

EO

1

3/1

NAIC

Note P

 

20

Schedule SIS

1

N/A

N/A

3/1

NAIC

 

 

21

Supplemental Compensation Exhibit

1

N/A

N/A

3/1

NAIC

 

 

22

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

xxx

EO

xxx

4/1

NAIC

 

 

23

Supplemental Health Care Exhibit’s Allocation Report

xxx

EO

xxx

4/1

NAIC

 

 

24

Supplemental Investment Risk Interrogatories

1

EO

1

4/1

NAIC

 

 

25

Supplemental Schedule O

1

EO

xxx

3/1

NAIC

 

 

26

Supplemental Term and Universal Life Insurance Reinsurance
Exhibit

1

EO

1

4/1

NAIC

 

 

27

Trusteed Surplus Statement (Aliens)

1

EO

1

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

NAIC

 

 

28

Variable Annuities Supplement

1

EO

1

4/1

NAIC

 

 

29

VM 20 Reserves Supplement

xxx

EO

xxx

3/1

NAIC

 

 

30

Workers’ Compensation Carve Out Supplement

1

EO

1

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 (formerly Companywide
Exemption)

1

EO

xxx

Commissioner
7/1 NAIC 8/15

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,
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

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

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 (Regulation 74)

1

0

1

3/1

State

Note U

 

104

Corporate Governance Annual Disclosure***

1

0

1

6/1

Company

Note V

 

105

Filings Checklist (with Column 1 completed)

1

0

1

 

State

 

 

106

Form B-Holding Company Registration Statement

1

0

1

5/1

Company

 

 

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

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.

***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, see the following NAIC URL: http://www.naic.org/public_lead_state_report.htm.

****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-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: [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):
Ms. Ellen Caesar, Life Bureau
New York State Department of Financial Services One State Street
New York, NY 10004

Quarterly Statement (hard copies):
Ms. Ellen Caesar, Life 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 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.

Diskettes 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 Department of Financial Services’ 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 Department of Financial Services’ 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:

Assessment of Internal Controls Relative to Derivatives should be sent to Victor Agbu as indicated in Note T.

O

Internet Filing:

Instructions concerning internet filing alternative to filing diskette with New York for New York Supplement are set forth in Insurance Circular Letter No. 4 (2001).

All companies are strongly encouraged to file national form filings (as identified in items 61 through 71 in the checklist) with the NAIC, preferably via the Internet. By filing over the Internet or via diskette with the NAIC, an insurer will have fulfilled its electronic filing requirement for national forms with New York and therefore should not file a diskette with the Department.

P

Risk-Based Capital Report:

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

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

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

S

Audited Financial Statements

Ms. Ellen Caesar, 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. 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

Corporate Governance Annual Disclosure, Enterprise Risk Report and ORSA

Submit electronically through the Department’s Insurance Company and Fraternal Benefit Society Filings 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.