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Life, Accident And Health Insurers

Click here for a printable table form of the checklist for Life, Accident and Health 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”)

2

EO

xxx

3/1

NAIC

I

 

1.1

Printed Investment Schedule detail (Pages E01-E27)

2

EO

xxx

3/1

NAIC

I

 

2

Quarterly Financial Statement (8 ½” x 14”)

1

EO

xxx

5/15, 8/15, 11/15

NAIC

I

 

3

Separate Accounts Annual Statement (8 ½”x14”)

2

EO

xxx

3/1

NAIC

I

 

 

 

 

 

 

 

 

 

 

 

II.  NAIC SUPPLEMENTS

 

 

10

Accident & Health Policy Experience Exhibit

1

EO

xxx

4/1

NAIC

 

 

11

Analysis of Annuity Operations by Lines of Business

1

EO

xxx

4/1

NAIC

 

 

12

Analysis of Increase in Annuity Reserves During Year

1

EO

xxx

4/1

NAIC

 

 

13

Credit Insurance Experience Exhibit

1

EO

xxx

4/1

NAIC

 

 

14

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

1

EO

xxx

4/1

NAIC

 

 

15

Health Care Exhibit’s Allocation Report Supplement

1

EO

xxx

4/1

NAIC

 

 

16

Interest Sensitive Life Insurance Products Report

1

EO

xxx

4/1

NAIC

 

 

17

Investment Risk Interrogatories

1

EO

xxx

4/1

NAIC

 

 

18

Life, Health & Annuity Guaranty Assessment Base
Reconciliation Exhibit

1

EO

xxx

4/1

NAIC

 

 

19

Life, Health & Annuity Guaranty Assessment Base Reconciliation  Exhibit Adjustment Form

1

EO

xxx

4/1

NAIC

 

 

20

Long-term Care Experience Reporting Forms

1

EO

xxx

4/1

NAIC

 

 

21

Management Discussion & Analysis

1

EO

xxx

4/1

Company

 

 

22

Medicare Supplement Insurance Experience Exhibit

1

EO

xxx

3/1

NAIC

 

 

23

Medicare Part D Coverage Supplement

1

EO

xxx

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

NAIC

 

 

24

Risk-Based Capital Report

1

EO

xxx

3/1

NAIC

 

 

25

Schedule SIS

1

N/A

N/A

3/1

NAIC

 

 

26

Supplemental Compensation Exhibit

1

N/A

N/A

3/1

NAIC

 

 

27

Supplemental Schedule O

1

EO

xxx

3/1

NAIC

 

 

28

Trusteed Surplus Statement

1

EO

xxx

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

NAIC

 

 

29

Workers’ Compensation Carve-Out Supplement

1

EO

xxx

3/1

NAIC

 

 

30

Supplemental XXX/AXXX Reinsurance Exhibit

1

EO

xxx

4/1

NAIC

 

 

 

Actuarial Related Items

 

 

31

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

1

EO

xxx

3/1

Company

 

 

32

Actuarial Certification Related to Hedging required by Actuarial Guideline XLIII

1

EO

xxx

3/1

Company

 

 

33

Actuarial Certification Related to Reserves required by Actuarial Guideline XLIII

1

EO

xxx

3/1

Company

 

 

34

Actuarial Certification regarding use 2001 Preferred Class Table

1

EO

xxx

3/1

Company

 

 

35

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

1

N/A

xxx

4/30

Company

 

 

36

Actuarial Opinion

1

EO

xxx

3/1

Company

 

 

37

Actuarial Opinion on X-Factors

1

EO

xxx

3/1

Company

 

 

38

Actuarial Opinion on Separate Accounts Funding Guaranteed Minimum Benefit

1

EO

xxx

3/1

Company

 

 

39

Actuarial Opinion on Synthetic Guaranteed Investment Contracts

1

EO

xxx

3/1

Company

 

 

40

Actuarial Opinion required by Modified Guaranteed Annuity Model Regulation

1

EO

xxx

3/1

Company

 

 

41

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

1

EO

xxx

3/1

Company

 

 

42

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

1

EO

xxx

3/1

Company

 

 

43

Reasonableness of Assumptions Certification required by Actuarial Guideline XXXV

1

EO

xxx

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

Company

 

 

44

Reasonableness & Consistency of Assumptions Certification required by Actuarial Guideline XXXV

1

EO

xxx

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

Company

 

 

45

Reasonableness of Assumptions Certification for Implied Guaranteed Rate Method required by Actuarial Guideline XXXVI

1

EO

xxx

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

Company

 

 

46

Reasonableness & Consistency of Assumptions Certification  required by Actuarial Guideline XXXVI (Updated Average Market Value)

1

EO

xxx

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

Company

 

 

47

Reasonableness & Consistency of Assumptions Certification required by Actuarial Guideline XXXVI (Updated Market Value)

1

EO

xxx

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

Company

 

 

48

RBC Certification required under C-3 Phase I

1

EO

xxx

3/1

Company

 

 

49

RBC Certification required under C-3 Phase II

1

EO

xxx

3/1

Company

 

 

50

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

1

EO

N/A

3/1

Company

 

 

51

Statement on par/non-par policies – Exhibit 5 Int. 1&2

1

EO

N/A

3/1

Company

 

 

52

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

1

EO

N/A

6/1

Company

 

 

82

Audited Financial Reports

1

EO

N/A

6/1

Company

 

 

83

Audited Financial Reports Exemption Affidavit

1

N/A

N/A

 

Company

 

 

84

Communication of Internal Control Related Matters Noted in Audit

1

N/A

N/A

8/1

Company

 

 

85

Independent CPA (change)

1

N/A

N/A

 

Company

 

 

86

Management’s Report of Internal Control Over Financial Reporting

1

N/A

N/A

8/1

Company

 

 

87

Notification of Adverse Financial Condition

1

N/A

N/A

 

Company

 

 

88

Request for Exemption to File

1

N/A

N/A

 

Company

 

 

89

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

1

EO

N/A

3/1

Company

 

 

90

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

1

EO

N/A

3/1

Company

 

 

91

Relief from the Requirements for Audit Committees

1

EO

N/A

3/1

Company

 

 

 

 

 

 

 

 

 

 

 

 

V.  STATE REQUIRED FILINGS***

 

 

101

Advertising Certificate

1

0

1

3/1

Company

P

 

102

Annual Report Supplement(Rule945)

1

0

1

3/1

State

P

 

103

Carrier Reporting Form

1

0

1

2/1

State

P

 

104

Certificate of Compliance

1

0

xxx

3/1

State

 

 

105

Certificate of Deposit

1

0

xxx

3/1

State

P

 

106

Certificate of Valuation

1

0

xxx

3/1

State

 

 

107

Consumer Complaint Contact Update

1

0

1

3/1

Company

P

 

108

Exam Assessment Fee

1

0

xxx

3/1

State

C, D

 

109

Filings Checklist (with Column 1 completed)

1

0

xxx

3/1

State

 

 

110

Form B Holding Company Registration Statement

1

0

xxx

5/1

Company

H, J

 

111

Health Insurance Annual Data Report (Rule 940)

1

0

1

4/30

State

P

 

112

Health Report Card Survey

1

0

1

3/1

State

P

 

113

Long-Term Care Report (Rule 425)

1

0

1

6/30

State

P

 

114

Maine Fraud and Abuse

1

0

1

3/1

3/1

P

 

115

Managing General Agent

1

0

1

3/1

State

P

 

116

Mandated Benefit Experience Report (Bulletin 292)

1

0

1

4/30

State

P

 

117

Medical Loss Ratio Reporting and Rebates (24-A MRSA §4319 and Rule 940, Section 13)

1

0

1

6/1

State

P

 

118

Premium Tax

1

0

1

3/15

State

E

 

119

Signed Jurat

1

0

xxx

3/1,5/15,8/1511/15

State

 

 

120

State Filing Fees

1

0

1

8/10

State

C, P

 

121

State Page for Maine

1

0

xxx

3/1

Company

 

 

122

Supplemental Health Insurance Report (Bulletin 286-A)

1

0

1

4/1

State

P

 

123

Tick borne Disease Report

1

0

1

2/1

State

P

 

 

 

 

 

 

 

 

 

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