NAIC and Department of Financial Services Annual Statement Checklist and Instructions

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 (if applicable)

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

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):
Mr. Stephen Pallas, Life Bureau
New York State Department of Financial Services One State Street
New York, NY 10004

Quarterly Statement (hard copies):
Mr. Stephen Pallas, 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:

None

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:

Mr. Stephen Pallas, 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

Mr. Stephen Pallas, 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.