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Fraternal Societies

Click here for a printable table form of the checklist for Fraternal Insurers in Word or Adobe PDF format.

Company Name:_______________________   NAIC Company Code: _________
Contact:_____________________________   Telephone: _________________
REQUIRED FILINGS IN THE STATE OF: Maine   Filings Made During the Year 2015

(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”)

xxx

EO

xxx

3/1

NAIC

 

 

1.1

Printed  Investment Schedule detail (Pages E01-E27)

xxx

EO

xxx

3/1

NAIC

 

 

2

Quarterly Financial Statement (8 ½” x 14”)

xxx

EO

xxx

5/15, 8/15, 11/15

NAIC

 

 

3

Separate Accounts Annual Statement (8 ½”x 14”)

xxx

EO

xxx

3/1

NAIC

 

 

 

 

 

 

 

 

 

 

 

 

II.  NAIC SUPPLEMENTS

 

 

10

Accident & Health Policy Experience Exhibit

xxx

EO

xxx

4/1

NAIC

 

 

11

Analysis of Annuity Operations by Lines of Business

xxx

EO

xxx

4/1

NAIC

 

 

12

Analysis of Increase in Annuity Reserves During Year

xxx

EO

xxx

4/1

NAIC

 

 

13

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

xxx

EO

xxx

4/1

NAIC

 

 

14

Health Care Exhibit’s Allocation Report Supplement

xxx

EO

xxx

4/1

NAIC

 

 

15

Interest Sensitive Life Insurance Products Report

xxx

EO

xxx

4/1

NAIC

 

 

16

Investment Risk Interrogatories

xxx

EO

xxx

4/1

NAIC

 

 

17

Long-Term Care Experience Reporting Forms

xxx

EO

xxx

4/1

NAIC

 

 

18

Management Discussion & Analysis

xxx

EO

xxx

4/1

Company

 

 

19

Medicare Supplement Insurance Experience Exhibit

xxx

EO

xxx

3/1

NAIC

 

 

20

Medicare Part D Coverage Supplement

xxx

EO

xxx

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

NAIC

 

 

21

Risk-Based Capital Report

xxx

EO

xxx

3/1

NAIC

 

 

22

Supplemental Compensation Exhibit

xxx

N/A

N/A

3/1

NAIC

 

 

23

Trusteed Surplus Statement

xxx

EO

xxx

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

NAIC

 

 

24

Supplemental XXX/AXXX Reinsurance Exhibit

xxx

EO

xxx

4/1

NAIC

 

 

 

Actuarial Related Items

 

 

25

Actuarial Certification Related Annuity Non-forfeiture Ongoing Compliance for Equity Indexed Annuities

xxx

EO

xxx

3/1

Company

 

 

26

Actuarial Certification Related to Hedging required by Actuarial Guideline XLIII

xxx

EO

xxx

3/1

Company

 

 

27

Actuarial Certification Related to Reserves required by Actuarial Guideline XLIII

xxx

EO

xxx

3/1

Company

 

 

28

Actuarial Certification regarding use 2001 Preferred Class Table

xxx

EO

xxx

3/1

Company

 

 

29

Actuarial Memorandum Related to Universal Life with Secondary Guarantee Policies required by Actuarial Guideline XXXVIII 8D

1

N/A

N/A

4/30

Company

 

 

30

Actuarial Opinion

xxx

EO

xxx

3/1

Company

 

 

31

Actuarial Opinion on X-Factors

xxx

EO

xxx

3/1

Company

 

 

32

Actuarial Opinion on Separate Accounts Funding Guaranteed Minimum Benefit

xxx

EO

xxx

3/1

Company

 

 

33

Actuarial Opinion on Synthetic Guaranteed Investment Contracts

xxx

EO

xxx

3/1

Company

 

 

34

Actuarial Opinion required by Modified Guaranteed Annuity Model Regulation

xxx

EO

xxx

3/1

Company

 

 

35

Financial Officer Certification Related to Clearly Defined Hedging Strategy required by Actuarial Guideline XLIII

xxx

EO

xxx

3/1

Company

 

 

36

Management Certification that the Valuation Reflects Management’s Intent required by Actuarial Guideline XLIII

xxx

EO

xxx

3/1

Company

 

 

37

Reasonableness of Assumptions Certification required by Actuarial Guideline XXXV

xxx

EO

xxx

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

Company

 

 

38

Reasonableness & Consistency of Assumptions Certification required by Actuarial Guideline XXXV

xxx

EO

xxx

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

Company

 

 

39

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

 

 

40

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

 

 

41

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

 

 

42

RBC Certification required under C-3 Phase I

xxx

EO

xxx

3/1

Company

 

 

43

RBC Certification required  under C-3 Phase II

xxx

EO

xxx

3/1

Company

 

 

44

Statement on non-guaranteed elements – Exhibit 5 Int. #3

xxx

EO

xxx

3/1

Company

 

 

45

Statement on participating/non-participating policies – Exhibit 5, Inter. #1&2

xxx

EO

xxx

3/1

Company

 

 

46

RAAIS required by Actuarial Opinion and Memorandum Regulation (Model 872), Section 7A(5)

1

N/A

1

3/15

Company

 

 

 

 

 

 

 

 

 

 

 

 

III. ELECTRONIC FILING REQUIREMENTS

 

 

60

Annual Statement Electronic Filing

xxx

EO

xxx

3/1

NAIC

 

 

61

March .PDF Filing

xxx

EO

xxx

3/1

NAIC

 

 

62

Risk-Based Capital Electronic Filing

xxx

EO

N/A

3/1

NAIC

 

 

63

Risk-Based Capital .PDF Filing

xxx

EO

N/A

3/1

NAIC

 

 

64

Separate Accounts Electronic Filing

xxx

EO

xxx

3/1

NAIC

 

 

65

Separate Accounts .PDF Filing

xxx

EO

xxx

3/1

NAIC

 

 

66

Supplemental Electronic Filing

xxx

EO

xxx

4/1

NAIC

 

 

67

Supplemental .PDF Filing

xxx

EO

xxx

4/1

NAIC

 

 

68

Quarterly Statement Electronic Filing

xxx

EO

xxx

5/15, 8/15 & 11/15

NAIC

 

 

69

Quarterly .PDF Filing

xxx

EO

xxx

5/15, 8/15 & 11/15

NAIC

 

 

70

June .PDF Filing

xxx

EO

xxx

6/1

NAIC

 

 

 

 

 

 

 

 

 

 

 

 

IV.  AUDIT/INTERNAL CONTROL
RELATED REPORTS

 

 

81

Accountants Letter of Qualifications

xxx

EO

N/A

6/1

Company

 

 

82

Audited Financial Reports

xxx

EO

N/A

6/1

Company

 

 

83

Audited Financial Reports Exemption Affidavit

xxx

N/A

N/A

 

Company

 

 

84

Communication of Internal Control Related Matters Noted in Audit

xxx

N/A

N/A

8/1

Company

 

 

85

Independent CPA (change)

xxx

N/A

N/A

 

Company

 

 

86

Management’s Report of Internal Control Over Financial Reporting

xxx

N/A

N/A

8/1

Company

 

 

87

Notification of Adverse Financial Condition

xxx

N/A

N/A

 

Company

 

 

88

Request for Exemption to File

xxx

N/A

N/A

 

Company

 

 

89

Relief from the five-year rotation requirement for lead audit partner

xxx

EO

N/A

3/1

Company

 

 

90

Relief from the one-year cooling off period for independent CPA

xxx

EO

N/A

3/1

Company

 

 

91

Relief from the Requirements for Audit Committees

xxx

EO

N/A

3/1

Company

 

 

 

 

 

 

 

 

 

 

 

 

V.  STATE REQUIRED FILINGS***

 

 

101

Advertising Certificate (Rule Chapter 140§B)

xxx

0

1

3/1

Company

 

 

102

Affidavit of Filing

xxx

0

xxx

3/1

State

 

 

103

Annual Report Supplement

xxx

0

1

3/1

State

P

 

104

Carrier Reporting Form

xxx

0

1

2/1

State

P

 

105

Certificate of Compliance

xxx

0

xxx

3/1

State

 

 

106

Certificate of Deposit

xxx

0

xxx

3/1

State

 

 

107

Certificate of Valuation

xxx

0

xxx

3/1

State

 

 

108

Filings Checklist (with Column 1 completed)

xxx

0

xxx

3/1

State

 

 

109

Maine Fraud and Abuse Annual Report

xxx

0

1

3/1

 

 

 

110

Mandated Benefit Expense Report (Bulletin 292)

xxx

0

1

4/30

State

P

 

111

Premium Tax

xxx

0

1

3/15

State

E

 

112

Signed Jurat

xxx

0

xxx

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

NAIC

 

 

113

State Filing Fees

xxx

0

1

8/10

State

C, P

 

114

Supplemental Health Insurance Report (Bulletin 286-A)

xxx

0

1

4/1

State

P

 

115

Tick Borne Disease Report

xxx

0

1

2/1

State

P

 

 

 

 

 

 

 

 

 

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

 

 

NOTES AND INSTRUCTIONS (A-K APPLY TO ALL FILINGS)

GENERAL INSTRUCTIONS FOR COMPANIES TO USE CHECKLIST

 

Last Updated: October 24, 2014