(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 |
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State |
NAIC |
State |
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I. NAIC FINANCIAL STATEMENTS |
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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 |
|
|
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 |
|
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|
|
|
II. NAIC SUPPLEMENTS |
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10 |
Accident & Health Policy Experience Exhibit |
1 |
EO |
xxx |
4/1 |
NAIC |
|
|
11 |
Actuarial Certification Related Annuity Nonforfeiture Ongoing Compliance for Equity Indexed Annuities |
1 |
EO |
xxx |
3/1 |
Company |
|
|
12 |
Actuarial Certification Related to Hedging required by Actuarial Guideline XLIII |
1 |
EO |
xxx |
3/1 |
Company |
|
|
13 |
Actuarial Certification Related to Reserves required by Actuarial Guideline XLIII |
1 |
EO |
xxx |
3/1 |
Company |
|
|
14 |
Actuarial Certification regarding use 2001 Preferred Class Table |
1 |
EO |
xxx |
3/1 |
Company |
|
|
15 |
Actuarial Opinion |
1 |
EO |
xxx |
3/1 |
Company |
|
|
16 |
Actuarial Opinion on X-Factors |
1 |
EO |
xxx |
3/1 |
Company |
|
|
17 |
Actuarial Opinion on Separate Accounts Funding Guaranteed Minimum Benefit |
1 |
EO |
xxx |
3/1 |
Company |
|
|
18 |
Actuarial Opinion on Synthetic Guaranteed Investment Contracts |
1 |
EO |
xxx |
3/1 |
Company |
|
|
19 |
Actuarial Opinion required by Modified Guaranteed Annuity Model Regulation |
1 |
EO |
xxx |
3/1 |
Company |
|
|
20 |
Analysis of Annuity Operations by Lines of Business |
1 |
EO |
xxx |
4/1 |
NAIC |
|
|
21 |
Analysis of Increase in Annuity Reserves During Year |
1 |
EO |
xxx |
4/1 |
NAIC |
|
|
22 |
Credit Insurance Experience Exhibit |
1 |
EO |
xxx |
4/1 |
NAIC |
|
|
23 |
Financial Officer Certification Related to Clearly Defined Hedging Strategy required by Actuarial Guideline XLIII |
1 |
EO |
xxx |
3/1 |
Company |
|
|
24 |
Health Care Exhibit (Parts 1, 2 and 3) Supplement |
1 |
EO |
xxx |
4/1 |
NAIC |
|
|
25 |
Health Care Exhibit’s Allocation Report Supplement |
1 |
EO |
|
4/1 |
NAIC |
|
|
26 |
Interest Sensitive Life Insurance Products Report |
1 |
EO |
xxx |
4/1 |
NAIC |
|
|
27 |
Investment Risk Interrogatories |
1 |
EO |
xxx |
4/1 |
NAIC |
|
|
28 |
Life, Health & Annuity Guaranty Assessment Base
Reconciliation Exhibit |
1 |
EO |
xxx |
4/1 |
NAIC |
|
|
29 |
Life, Health & Annuity Guaranty Assessment Base Reconciliation Exhibit Adjustment Form |
1 |
EO |
xxx |
4/1 |
NAIC |
|
|
30 |
Long-term Care Experience Reporting Forms |
1 |
EO |
xxx |
4/1 |
NAIC |
|
|
31 |
Management Certification that the Valuation Reflects Management’s Intent required by Actuarial Guideline XLIII |
1 |
EO |
xxx |
3/1 |
Company |
|
|
32 |
Management Discussion & Analysis |
1 |
EO |
xxx |
4/1 |
Company |
|
|
33 |
Medicare Supplement Insurance Experience Exhibit |
1 |
EO |
xxx |
3/1 |
NAIC |
|
|
34 |
Medicare Part D Coverage Supplement |
1 |
EO |
|
3/1, 5/15, 8/15, 11/15 |
NAIC |
|
|
35 |
Reasonableness of Assumptions Certification required by Actuarial Guideline XXXV |
1 |
EO |
xxx |
3/1,5/15, 8/15, 11/15 |
Company |
|
|
36 |
Reasonableness & Consistency of Assumptions Certification required by Actuarial Guideline XXXV |
1 |
EO |
xxx |
3/1,5/15, 8/15, 11/15 |
Company |
|
|
37 |
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 |
|
|
38 |
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 |
|
|
39 |
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 |
|
|
40 |
Risk-Based Capital Report |
1 |
EO |
xxx |
3/1 |
NAIC |
|
|
41 |
RBC Certification required under C-3 Phase I |
1 |
EO |
xxx |
3/1 |
Company |
|
|
42 |
RBC Certification required under C-3 Phase II |
1 |
EO |
xxx |
3/1 |
Company |
|
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43 |
Schedule SIS |
1 |
N/A |
N/A |
3/1 |
NAIC |
|
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44 |
Statement on non-guaranteed elements - Exhibit 5 Int. #3 |
1 |
EO |
xxx |
3/1 |
Company |
|
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45 |
Statement on par/non-par policies – Exhibit 5 Int. 1&2 |
1 |
EO |
N/A |
3/1 |
Company |
|
|
46 |
Supplemental Compensation Exhibit |
1 |
N/A |
N/A |
3/1 |
NAIC |
|
|
47 |
Supplemental Schedule O |
1 |
EO |
xxx |
3/1 |
NAIC |
|
|
48 |
Trusteed Surplus Statement |
1 |
EO |
xxx |
3/1, 5/15, 8/15, 11/15 |
NAIC |
|
|
49 |
Workers’ Compensation Carve-Out Supplement |
1 |
EO |
xxx |
3/1 |
NAIC |
|
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III. ELECTRONIC FILING REQUIREMENTS |
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|
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 |
NAIC |
|
|
60 |
June .PDF Filing |
xxx |
EO |
xxx |
6/1 |
NAIC |
|
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IV. AUDIT/INTERNAL CONTROL RELATED REPORTS |
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|
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|
71 |
Accountants Letter of Qualifications |
1 |
EO |
N/A |
6/1 |
Company |
|
|
72 |
Audited Financial Reports |
1 |
EO |
N/A |
6/1 |
Company |
|
|
73 |
Audited Financial Reports Exemption Affidavit |
1 |
N/A |
N/A |
|
Company |
|
|
74 |
Communication of Internal Control Related Matters Noted in Audit |
1 |
N/A |
N/A |
8/1 |
Company |
|
|
75 |
Independent CPA (change) |
1 |
N/A |
N/A |
|
Company |
|
|
76 |
Management’s Report of Internal Control Over Financial Reporting |
1 |
N/A |
N/A |
8/1 |
Company |
|
|
77 |
Notification of Adverse Financial Condition |
1 |
N/A |
N/A |
|
Company |
|
|
78 |
Request for Exemption to File |
1 |
N/A |
N/A |
|
Company |
|
|
79 |
Relief from the five-year rotation requirement for lead audit partner |
1 |
EO |
N/A |
3/1 |
Company |
|
|
80 |
Relief from the one-year cooling off period for independent CPA |
1 |
EO |
N/A |
3/1 |
Company |
|
|
81 |
Relief from the Requirements for Audit Committees |
1 |
EO |
N/A |
3/1 |
Company |
|
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V. STATE REQUIRED FILINGS*** |
|
|
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|
|
101 |
Advertising Certificate |
1 |
0 |
1 |
3/1 |
Company |
P |
|
102 |
Affidavit of Filing |
0 |
0 |
N/A |
3/1 |
State |
|
|
103 |
Annual Report Supplement (Rule 945) |
1 |
0 |
1 |
3/1 |
State |
P |
|
104 |
Carrier Reporting Form |
1 |
0 |
1 |
2/1 |
State |
P |
|
105 |
Certificate of Compliance |
1 |
0 |
xxx |
3/1 |
State |
|
|
106 |
Certificate of Deposit |
1 |
0 |
xxx |
3/1 |
State |
P |
|
107 |
Certificate of Valuation |
1 |
0 |
xxx |
3/1 |
State |
|
|
108 |
Consumer Complaint Contact Update |
1 |
0 |
1 |
3/1 |
Company |
P |
|
109 |
Exam Assessment Fee |
1 |
0 |
xxx |
3/1 |
State |
C, D |
|
110 |
Filings Checklist (with Column 1 completed) |
1 |
0 |
xxx |
3/1 |
State |
|
|
111 |
Form B Holding Company Registration Statement |
1 |
0 |
xxx |
5/1 |
Company |
H, J |
|
112 |
Health Insurance Annual Data Report (Rule 940) |
1 |
0 |
1 |
4/30 |
State |
P |
|
113 |
Health Report Card Survey |
1 |
0 |
1 |
3/1 |
State |
P |
|
114 |
Maine Fraud and Abuse Report |
1 |
0 |
1 |
3/1 |
State |
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, Sec. 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, 8/15, 11/15 |
NAIC |
|
|
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 |
|
|
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