Fraternal Societies

(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”)

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

4/1

NAIC

11

Actuarial Certification Related Annuity Nonforfeiture Ongoing Compliance for Equity Indexed Annuities

XXX

EO

3/1

Company

12

Actuarial Certification Related to Hedging required by Actuarial Guideline XLIII

XXX

EO

3/1

Company

13

Actuarial Certification Related to Reserves required by Actuarial Guideline XLIII

XXX

EO

3/1

Company

14

Actuarial Certification regarding use 2001 Preferred Class Table

XXX

EO

3/1

Company

15

Actuarial Opinion

XXX

EO

3/1

Company

16

Actuarial Opinion on X-Factors

XXX

EO

3/1

Company

17

Actuarial Opinion on Separate Accounts Funding Guaranteed Minimum Benefit

XXX

EO

3/1

Company

18

Actuarial Opinion on Synthetic Guaranteed Investment Contracts

XXX

EO

3/1

Company

19

Actuarial Opinion required by Modified Guaranteed Annuity Model Regulation

XXX

EO

3/1

Company

20

Analysis of Annuity Operations by Lines of Business

XXX

EO

4/1

NAIC

21

Analysis of Increase in Annuity Reserves During Year

XXX

EO

4/1

NAIC

22

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

XXX

EO

3/1

Company

23

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

XXX

EO

4/1

NAIC

24

Health Care Exhibit’s Allocation Report Supplement

XXX

EO

4/1

NAIC

25

Interest Sensitive Life Insurance Products Report

XXX

EO

XXX

4/1

NAIC

26

Investment Risk Interrogatories

XXX

EO

4/1

NAIC

27

Long-term Care Experience Reporting Forms

XXX

EO

XXX

4/1

NAIC

28

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

XXX

EO

3/1

Company

29

Management Discussion & Analysis

XXX

EO

4/1

Company

30

Medicare Supplement Insurance Experience Exhibit

XXX

EO

XXX

3/1

NAIC

31

Medicare Part D Coverage Supplement

XXX

EO

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

NAIC

32

Reasonableness of Assumptions Certification required by Actuarial Guideline XXXV

XXX

EO

XXX

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

Company

33

Reasonableness & Consistency of Assumptions Certification required by Actuarial Guideline XXXV

XXX

EO

XXX

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

Company

34

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

35

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

36

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

37

Risk-Based Capital Report

XXX

EO

3/1

NAIC

38

RBC Certification required under C-3 Phase I

XXX

EO

3/1

Company

39

RBC Certification required  under C-3 Phase II

XXX

EO

3/1

Company

40

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

XXX

EO

3/1

Company

41

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

XXX

EO

3/1

Company

42

Supplemental Compensation Exhibit

XXX

N/A

N/A

3/1

NAIC

43

Trusteed Surplus Statement

XXX

EO

XXX

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

NAIC

III. ELECTRONIC FILING REQUIREMENTS

50

Annual Statement Electronic Filing

XXX

EO

XXX

3/1

NAIC

51

March .PDF Filing

XXX

EO

XXX

3/1

NAIC

52

Risk-Based Capital Electronic Filing

XXX

EO

N/A

3/1

NAIC

53

Risk-Based Capital .PDF Filing

XXX

EO

N/A

3/1

NAIC

54

Separate Accounts Electronic Filing

XXX

EO

XXX

3/1

NAIC

55

Separate Accounts .PDF Filing

XXX

EO

XXX

3/1

NAIC

56

Supplemental Electronic Filing

XXX

EO

XXX

4/1

NAIC

57

Supplemental .PDF Filing

XXX

EO

XXX

4/1

NAIC

58

Quarterly Statement Electronic Filing

XXX

EO

XXX

5/15, 8/15 & 11/15

NAIC

59

Quarterly .PDF Filing

XXX

EO

XXX

5/15, 8/15 & 11/15

60

June .PDF Filing

XXX

EO

XXX

6/1

NAIC

IV.  AUDIT/INTERNAL CONTROL RELATED REPORTS

71

Accountants Letter of Qualifications

XXX

EO

N/A

6/1

Company

72

Audited Financial Reports

XXX

EO

6/1

Company

73

Audited Financial Reports Exemption Affidavit

XXX

N/A

N/A

Company

74

Communication of Internal Control Related Matters Noted in Audit

XXX

N/A

N/A

8/1

Company

75

Independent CPA (change)

XXX

N/A

N/A

Company

76

Management’s Report of Internal Control Over Financial Reporting

XXX

N/A

N/A

8/1

Company

77

Notification of Adverse Financial Condition

XXX

N/A

N/A

Company

78

Request for Exemption to File

XXX

N/A

N/A

Company

79

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

XXX

EO

N/A

3/1

Company

80

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

XXX

EO

N/A

3/1

Company

81

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

Filings Checklist (with Column 1 completed)

XXX

0

XXX

3/1

State

108

Maine Fraud and Abuse Annual Report

XXX

0

1

3/1

State

P

109

Mandated Benefit Expense Report (Bulletin 292)

XXX

0

1

4/30

State

P

110

Premium tax

XXX

0

1

3/15

State

E

111

Signed Jurat

XXX

0

XXX

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

NAIC

112

State Filing Fees

XXX

XXX

1

8/10

State

C,P

113

Supplemental Health Insurance Report (Bulletin 286-A)

XXX

0

1

4/1

State

P

114

Tick Borne Disease Report

XXX

0

1

2/1

State

P