Property & Casualty Insurers 401 014 Fin122cklpc

User Manual: 401-014

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FIN122 | 0118
Texas Department of Insurance | www.tdi.texas.gov 1/9
PROPERTY & CASUALTY INSURERS
COMPANY NAME: NAIC Company Code:
Contact: Telephone:
REQUIRED FILINGS IN THE STATE OF: TEXAS Filings Made During the Year 2018
(1)
Checklist
(2)
Line #
(3)
REQUIRED FILINGS FOR THE ABOVE STATE
(4)
NUMBER OF COPIES*
(5)
DUE DATE
(6)
FORM
SOURCE**
(7)
APPLICAB
LE
NOTES
Domestic
State
NAIC
I. NAIC FINANCIAL STATEMENTS
1
Annual Statement (8 ½” x 14”)
1
EO
3/1
NAIC
Q, Z, AA
1.1
Printed Investment Schedule detail (Pages E01-E27)
1
EO
3/1
NAIC
Q, Z, AA
2
Quarterly Financial Statement (8 ½” x 14”)
1
EO
5/15, 8/15, 11/15
NAIC
Q, Z, AA
3
Protected Cell Annual Statement
xxx
0
3/1
NAIC
U
4
Combined Annual Statement (8 ½” x 14”)
1
EO
5/1
NAIC
Q, Z, AA
II. NAIC SUPPLEMENTS
11
Accident & Health Policy Experience Exhibit
1
EO
4/1
NAIC
Q, Z
12
Actuarial Opinion
1
EO
3/1
Company
Q, Z
13
Actuarial Opinion Summary – Confidential filing. Submit to
Actuarial Office. +
1
N/A
3/15
Company
R, AK
14
Bail Bond Supplement
1
EO
3/1
NAIC
O, Z, AS
15
Combined Insurance Expense Exhibit
1
EO
5/1
NAIC
Q, Z
16
Credit Insurance Experience Exhibit
1
EO
4/1
NAIC
Q, Z
17
Cybersecurity and Identity Theft Insurance Coverage
Supplement
1
EO
4/1
NAIC
Q, Z
18
Director and Officer Insurance Coverage Supplement
1
EO
3/1, 5/15, 8/15, 11/15
NAIC
Q, Z, AW
19
Financial Guaranty Insurance Exhibit
1
EO
3/1
NAIC
Q, Z
20
Insurance Expense Exhibit
1
EO
4/1
NAIC
Q, Z
21
Long-Term Care Experience Reporting Forms
1
EO
4/1
NAIC
Q, Z
22
Management Discussion & Analysis
1
EO
4/1
Company
Q, Z
23
Medicare Part D Coverage Supplement
1
EO
3/1, 5/15, 8/15, 11/15
NAIC
Q, Z
24
Medicare Supplement Insurance Experience Exhibit
1
EO
3/1
NAIC
Q, Z
25
Premiums Attributed to Protected Cells Exhibit
1
EO
3/1
NAIC
Q, Z
26
Reinsurance Attestation Supplement
1
EO
3/1
Company
Q, Z
27
Exceptions to Reinsurance Attestation Supplement
1
N/A
3/1
Company
R
28
Reinsurance Summary Supplemental
1
EO
3/1
NAIC
Q, Z
29
Risk-Based Capital Report
0
EO
3/1
NAIC
O, Y, Z
30
Schedule SIS
1
N/A
3/1
NAIC
P, R
31
Supplement A to Schedule T
1
EO
3/1, 5/15, 8/15, 11/15
NAIC
Q, Z
32
Supplemental Compensation Exhibit
1
N/A
3/1
NAIC
P, R
33
Supplemental Health Care Exhibit (Parts 1, 2 and 3)
1
EO
4/1
NAIC
O, Z, AV
34
Supplemental Health Care Exhibit’s Allocation Report
Supplement
1
EO
4/1
NAIC
O, Z, AV
35
Supplemental Investment Risk Interrogatories
1
EO
4/1
NAIC
Q, Z
36
Supplemental Schedule for Reinsurance Counterparty
Reporting Exception – Asbestos and Pollution Contracts
0
EO
3/1
NAIC
N, Z
37
Trusteed Surplus Statement
1
EO
3/1, 5/15, 8/15, 11/15
NAIC
Q, Z
III. ELECTRONIC FILING REQUIREMENTS
61
Annual Statement Electronic Filing
xxx
EO
3/1
NAIC
O, Z
62
March .PDF Filing
xxx
EO
3/1
NAIC
O, Z
63
Risk-Based Capital Electronic Filing
xxx
EO
3/1
NAIC
O, Z
64
Risk-Based Capital .PDF Filing
xxx
EO
3/1
NAIC
O, Z
65
Combined Annual Statement Electronic Filing
xxx
EO
5/1
NAIC
O, Z
66
Combined Annual Statement .PDF Filing
xxx
EO
5/1
NAIC
O, Z
67
Supplemental Electronic Filing
xxx
EO
4/1
NAIC
O, Z
68
Supplemental .PDF Filing
xxx
EO
4/1
NAIC
O, Z
69
Quarterly Statement Electronic Filing
xxx
EO
5/15, 8/15, 11/15
NAIC
O, Z
70
Quarterly .PDF Filing
xxx
EO
5/15, 8/15, 11/15
NAIC
O, Z
71
June .PDF Filing
xxx
EO
xxx
6/1
NAIC
O, Z, AD
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(1)
Checklist
(2)
Line #
(3)
REQUIRED FILINGS FOR THE ABOVE STATE
(4)
NUMBER OF COPIES*
(5)
DUE DATE
(6)
FORM
SOURCE**
(7)
APPLICAB
LE
NOTES
Domestic
State
NAIC
IV. AUDIT/INTERNAL CONTROL
RELATED REPORTS
81
Accountants Letter of Qualifications (TIC § 401.013 and 28
TAC §7.88(I))
1
EO
6/1 or 6/30
Company
Q, Z
82
Audited Financial Reports (TIC Chapter 401 Subchapter B,
and 28 TAC §§7.18, 7.85 and 7.88)
1
EO
6/1 or 6/30
Company
Q, Z, AD
83
Audited Financial Reports Exemption Affidavit for Certain
Small Insurers and HMO’s (TIC §401.006)
1
N/A
6/1 or 6/30
Company
R, AG
84
Communication of Internal Control Related Matters Noted
in Audit (28 TAC 7.88(j))
1
EO
8/1 or 8/31
Company
P, AX
85
Independent CPA (change) (Designation of Accountant) (TIC
§401.014)
1
N/A
12/31
Company
R, AF
86
Management’s Report of Internal Control Over Financial
Reporting (28 TAC §7.88(m) and (n)(2) and (3))
1
N/A
8/1 or 8/31
Company
P, AX
87
Notification of Adverse Financial Condition or
Misstatement of Financial Condition (TIC § 401.017)
1
N/A
<5th business day after
notice received
Company
P, AD
88
Relief from the five-year rotation requirement for lead
audit partner (28 TAC §7.88 (h)(1) and (2))
1
EO
3/1
Company
Q, Z, AZ
89
Relief from the one-year cooling off period for independent
CPA (28 TAC §7.88 (h)(10) and (12))
1
EO
3/1
Company
Q, Z, AZ
90
Relief from the Requirements for Audit Committees (28
TAC §7.88 (k)(4))
1
EO
3/1
Company
Q, Z, AZ
91
Request to File Consolidated Audited Annual Statements
1
N/A
12/31
Company
P, AH
92
Request for Exemption to File Management’s Report of
Internal Control Over Financial Reporting (28 TAC §7.88
(j)(4))
1
N/A
8/1 or 8/31
Company
P, AX
V. STATE REQUIRED FILINGS***
101
Registration of Accountant (TIC §401.014)
1
0
12/31
Accountant
R, AF
102
Form B - Annual Holding Company Registration Statement
1
0
4/30
State
R, AE
103
Biographical Affidavit
1
0
As change occurs
State
P, X
104
Certificate of Compliance – Advertising
EO
0
3/1
Company
105
Filings Checklist (with Column 1 completed)
0
0
State
U
106
Premium Taxes – file with the Texas Comptroller of Public
Accounts +
1
0
Varies
State
P, V
107
Signed Jurat page - ONLY. Foreign companies are not
required to file annual/quarterly statements with TDI but
must submit a signed Jurat page. Foreign HMOs – see note
AA.
xxx
0
3/1, 5/15, 8/15, 11/15
NAIC
L, P, AA
108
State Filing Fees (Annual Statements) - File with the Texas
Comptroller of Public Accounts. +
1
0
Varies
State
P, V
109
Texas Officers and Directors Page
1
0
As change occurs
State
P, R, W
110
Texas Overhead Assessment Exemption Form (PDF)
1
0
3/1
State
P, R
111
Request for Permitted Accounting Practices
1
0
As needed
Company
R, AI
112
Texas Negotiated Deductible Workers’ Compensation
Form. CONFIDENTIAL filing. File upon request of TDI. Do
NOT include with Annual or Quarterly statement filings. +
1
0
As needed
State
P, R, AO
113
Texas Supplemental A For County Mutuals (PDF) (County
Mutuals Only)
1
0
3/1
State
P, R
114
Texas Supplement For County Mutuals (PDF) (County
Mutuals Only)
1
0
3/1
State
P, R
115
Policy Count Exhibit – Form; Instructions
(TIC §521.052 (1))
EO
0
3/1
State
N, BD
116
Corporate Governance Annual Disclosure***
1
0
Company
AE
117
Form F – Holding Company Enterprise Risk Report ****
file with TDI if Texas is the lead state
1
0
4/30
State
BB
118
ORSA (Own Risk and Solvency Assessment) *****
file with TDI if Texas is the lead state
1
0
Varies
Company
BC
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*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 Corporate Governance Annual Disclosure Model Act, an annual disclosure is required of all insurers
or insurance groups by June 1. The Corporate Governance Annual Disclosure 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 if filed at the insurance group level. For more information on
lead states, see the following NAIC URL: http://www.naic.org/public_lead_state_report.htm.
****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.
*****For those states that have adopted the NAIC Risk Management and Own Risk and Solvency Assessment Model Act, a summary report is
required annually by insurers and insurance groups above a specified premium threshold. The ORSA Summary Report 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 if filed at the
insurance group level. For more information on lead states, see the following NAIC URL: http://www.naic.org/public_lead_state_report.htm.
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+ This symbol along with the yellow highlighting are provided for emphasis only.
NOTES AND INSTRUCTIONS (A-K APPLY TO ALL FILINGS)
A
For questions regarding required filings, contact:
FinancialAnalysis@tdi.texas.gov
B
Mailing Address:
Street Address (carrier delivery, overnight mail, etc.):
Texas Department of Insurance
Financial Analysis MC 303-1A
PO Box 149104
Austin TX 78714-9104
Texas Department of Insurance
Financial Analysis MC 303-1A
333 Guadalupe St
Austin, TX 78701
C
Mailing Address for Annual Statement Filing Fees:
Refer to Annual Statement Filing Fee (Item 23) for amounts:
http://www.comptroller.texas.gov/forms/25-300.pdf
Texas Comptroller of Public Accounts
P.O. Box 149356
Austin, TX 78714-9356
(800) 252-1387
http://www.comptroller.texas.gov/
D
Mailing Address for Premium Tax Payments:
Refer to Texas Insurance Tax Forms at:
http://www.comptroller.texas.gov/taxes/insurance/
Texas Comptroller of Public Accounts
P.O. Box 149356
Austin, TX 78714-9356
(800) 252-1387
http://www.comptroller.texas.gov/
E
Delivery Instructions:
Filings must be postmarked by due date. If the due
date falls on a weekend or holiday, the due date is
extended to the next business day.
F
Late Filings:
Penalties and fines for late filings are provided for by
the Texas Insurance Code.
G
Original Signatures:
Original signatures are required on all filings from
domestic companies. Foreign/Alien insurers may
submit a photocopy of the original signed filing.
H
Signature/Notarization/Certification:
The following officers are required to sign
annual/quarterly statements: the President and two
principal officers.
I
Amended Filings:
If more than five pages are amended, submit an entire statement
including Jurat page with appropriate signatures.
To be submitted with cover letter and Jurat page signed
by the President and two principal officers.
J
Exceptions from normal filings:
None.
K
Bar Codes (State or NAIC):
NAIC Bar Codes are required and should be generated
according to NAIC instructions.
L
Signed Jurat:
Domestic+: original signatures
Foreign/Alien+: photo-copied signatures are accepted
Signed by the President and two principal officers.
M
NONE Filings:
“NONE” bar codes are allowed.
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+ This symbol along with the yellow highlighting are provided for emphasis only.
N
Filings new, discontinued or modified materially since last year:
New: Fraternal/Life Blanks - Variable Annuities
Supplement, VM 20 Reserves Supplement, Life PBR
Exemption, PBR Actuarial Report Executive Summary; All
Blanks - Corporate Governance Annual Disclosure
Discontinued: Health Blank - Property/Casualty
Supplements due 03/01 and 04/01
Modified: N/A
O
Filed with the NAIC only.
P
Filed hard copy with Texas only.
Q
Filed with the NAIC and Texas.
R
Required of Texas domestic companies only.
S
Required of foreign companies only.
T
Required of Texas domestic and foreign companies.
U
Not required to be filed.
V
To be filed with the State of Texas Comptroller of Public Accounts.
Questions? Call the Comptroller at 800-252-1387.
Texas Comptroller of Public Accounts
P.O. Box 149356
Austin, TX 78714-9356
(512) 463-4600
http://www.comptroller.texas.gov/
W
Texas Officers and Directors
TDI form FIN306 (Officers and Directors Page)
Required of Texas domestics when change occurs to an
executive officer/director, along with the Biographical
Affidavit.
X
Biographical Affidavit
Biographical affidavits must be submitted when a change occurs to
a company’s officers or directors.
FIN353 (Biographical Affidavit Instructions and Fingerprint
Requirements for Texas-Domestic Insurers)
NAIC UCAA, Form 11 (Biographical Affidavit)
Domestic insurers are required to submit Biographical
Affidavits and fingerprint receipts for all Directors and
only the following officers: CEO, President, Executive
Director, Secretary, Treasurer, CFO/Controller, COO and
Medical Director (if applicable). TDI does NOT require
biographical affidavits for Vice Presidents or Assistant-
officers.
Foreign insurers submit Bios for President, Secretary and
Treasurer only when changes occur.
Y
Risk-Based Capital Report
Required to be filed with TDI upon request.
Z
To be filed electronically with the NAIC.
AA
Foreign companies
Foreign companies shall file a Signed Jurat page with TDI.
Foreign HMOs must file a complete statement.
AB
Analysis of Surplus
Discontinued (2014)
AC
Recommended, not required.
AD
Audited Financial Statements
Companies receiving a Notification of Adverse Financial Condition or
a Report of Significant Deficiencies in Internal Control must provide
a copy of the notice to the Department not later than the 5th
business day after the date the insurer or HMO receives the notice
(TIC § 401.017).
Instructions for Filing CPA Audited Financial Report and Related
Filings for the Year 2017
Domestic Insurers: File hard copy with TDI by June 1 (or
June 30 if the insurer and its affiliate insurer(s) conduct
business only in Texas). See 28 TAC §7.88(d)(2).
Foreign Insurers: TDI will accept Annual Audited
Financial Statements filed with the NAIC in accordance
with the NAIC Electronic Filing Submission Directive in
lieu of filing a hard copy with TDI. Notification of
Adverse Financial Condition or a Report of Significant
Deficiencies in Internal Control must be filed with TDI.
AE
Annual Holding Company Registration Statement (Form B)
For Form B and other Holding Company filing fees, refer to
Transaction Cash Receipts Transmittal Form.
Applies to all Texas domestic and Commercially
domiciled insurers that are subject to the Insurance
Holding Company System Regulatory Act (Chapter 823).
AF
CPA Audited Financial Statement – Intent Form.
Texas Domestic Companies Only+
Complete this Texas supplemental form (Domestics
Only).
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+ This symbol along with the yellow highlighting are provided for emphasis only.
AG
CPA Audited Financial Statement – Affidavit for Exemption from
Filing CPA Report
Generally, an insurer may qualify for an exemption to file
a CPA report if direct written premiums in Texas were
less than $1 million. Insurers that have more than $1
million in assumed premiums are not exempt (TIC §
401.006).
AH
Request to file Consolidated Audited Annual Statement
Refer to TIC § 401.016.
AI
Request for Permitted Accounting Practices, submit to:
Jeff Hunt, Director
Texas Department of Insurance
Company Licensing & Registration MC 305-2C
PO Box 149104
Austin TX 78714-9104
Include the requested practice, the referenced SSAP
number, the reason for the request, and the financial
impact of the request.
AJ
Holding Company Filings
File Holding Company documents with TDI if any insurer
in the group is a Texas Domestic or is Commercially
Domiciled. Filings (not including Registration Statement)
are not required by Commercially Domiciled insurers, if
an exemption is in place. Foreign insurers file with their
Domestic state.
AK
Actuarial Opinion Summary – Confidential Filing.
Submit electronically+ to: ActuarialDivision@tdi.texas.gov
Property and Casualty Actuarial Opinion Summary (28
TAC §7.9). Confidential filing – file separately per Rule.
AL
Regulatory Asset Adequacy Issues Summary – Confidential Filing.
Submit electronically+ to: ActuarialDivision@tdi.texas.gov
All Domestic companies licensed as life, accident, &
health insurers must submit a RAAIS, unless exempt
according to 28 TAC §3.9902.
NOTE: Foreign companies must file upon request.
AM
Reasonableness of Assumptions Certification
Reasonableness & Consistency of Assumptions Certification
Actuarial certifications required for equity indexed
annuities as found in Actuarial Guideline XXXV, Appendix
C of the Accounting Practices and Procedures Manual.
AN
Reasonableness of Assumptions Certification for Implied
Guaranteed Rate Method
Reasonableness & Consistency of Assumptions
Certification (Updated Average Market Value)
Reasonableness & Consistency of Assumptions
Certification (Updated Market Value)
Actuarial certifications required for equity indexed life
insurance policies as found in Actuarial Guideline XXXVI,
Appendix C of the Accounting Practices and Procedures
Manual.
AO
Texas Negotiated Deductible Workers’ Compensation Form - place
in separate envelope clearly marked “Confidential – Texas
Negotiated Deductible Workers’ Comp Form”.+
Pursuant to 28 TAC 8.4. Required upon request, only for
companies writing this line of business.
AP
Actuarial Certification Related to Annuity Non-forfeiture
Compliance
Actuarial Opinion on Separate Accounts Funding
Actuarial Opinion on Synthetic Guaranteed Investment
Contracts
Actuarial Opinion required by Modified Guaranteed
Annuity Model Regulation
These filings should be completed in accordance with the
NAIC Model Regulations. Required upon request.
AQ
Actuarial Opinion on X-Factors
Actuarial Opinion required by APPM A-830.
AR
RBC Certification required under C-3 Phase I
RBC Certification required under C-3 Phase II
Required to be filed with TDI upon request.
AS
Bail Bond Supplement
Only reporting entities writing bail bond coverage are
required to complete this supplement. This supplement
must be filed with the NAIC by March 1 each year.
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+ This symbol along with the yellow highlighting are provided for emphasis only.
AT
Required by Actuarial Guideline XLIII
Actuarial Certification Related to Hedging
Actuarial Certification Related to Reserves
Financial Officer Certification Related to Clearly Defined
Hedging Strategy
Management Certification that the Valuation Reflects
Management’s Intent
Certifications required for variable annuities as found in
Actuarial Guideline XLIII, Appendix C of the Accounting
Practices and Procedures Manual.
AU
Supplemental Annuity Exhibits
Only reporting entities writing annuity products are
required to complete these exhibits.
AV
Supplemental Health Care Exhibits
Only reporting entities writing comprehensive major
medical insurance business for large group employer,
small group employer, and individual, are required to
complete these exhibits.
AW
Director and Officer Supplement
Only reporting entities providing director and officer
(D&O) liability coverage in a monoline policy or as part of
a commercial multiple peril (CMP) policy are required to
complete this supplement.
AX
Communication of Internal Control Matters Noted in Audit and
Report of Internal Control over Financial Reporting
Required to be filed no later than the 60th day after the
date of the audited financial report is filed (28 TAC
§§7.88(j)(1) and (m)(1)).
AY
Actuarial Certification Related to the Use of the 2001 Preferred
Class Mortality Tables
For all reporting entities that use the 2001 Preferred
Class Mortality Tables permitted by 28 TAC §§3.9401-
3.9404. This certification is required by §3.9404(a) and
(b).
AZ
Relief from Rotation, Cooling-Off, and Audit Committee
Requirements
Also see the Model Audit Rule Implementation Guide in
the NAIC’s Accounting Practices and Procedures Manual
- Appendix G (adopted by reference in 28 TAC §7.18).
BA
Actuarial Memorandum Related to Universal Life with Secondary
Guarantee Policies required by Actuarial Guideline XXXVIII – Section
8D – Confidential Filing. Requirements and guidance are found in
AG38 Section 8D(c) Documentation and Reporting.
Submit electronically+ to: ActuarialDivision@tdi.texas.gov
Applies to Texas domestic companies that have ULSG
business subject to AG38 Section 8D.
BB
Enterprise Risk Report – Form F
File if insurer meets the requirements of TIC
§823.0595(b)(1) and (2), and if Texas is the Lead State
Regulator of the holding company group (see Lead State
Report located at
http://www.naic.org/public_lead_state_report.htm).
BC
Own Risk and Solvency Assessment (ORSA)
Insurers or insurance groups subject to TIC Chapter 830
must file with the lead state commissioner an ORSA
Summary Report unless qualifying for an exemption
pursuant to §830.006.
BD
Policy Count Exhibit – Form
Submittal Instructions and Definitions
Annual filing used to determine complaint ratios. Due
date coincides with the annual statement filing. Read
the instructions thoroughly before completing the Policy
Count Exhibit form. Foreign Risk Retention Groups are
not required to submit this form.
BE
Principles Based Reserves (PBR) Filings
This filing is not required for those companies that have
elected to defer PBR during the 3-year transition period
(1/1/2017 to 12/31/2019) as permitted in VM Sec. II –
Life Products – C. No filing is anticipated for such
companies until 2020.
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General Instructions
For Companies to Use Checklist
Please Note: This state’s instructions for companies to file with the NAIC are included in this Checklist. The NAIC will not
be sending their own checklist this year.
Electronic filing is intended to be filing(s) submitted to the NAIC via the NAIC Internet Filing Site which
eliminates the need for a company to submit diskettes or CD-ROM to the NAIC. Companies are not required
to file hard copy filings with the NAIC.
Column (1) Checklist
Companies may use the checklist to submit to a state, if the state requests it. Companies should copy the checklist and place an “x” in
this column when mailing information to the state.
Column (2) Line #
Line # refers to a standard filing number used for easy reference. This line number may change from year to year.
Column (3) Required Filings
Name of item or form to be filed.
The Annual Statement Electronic Filing includes the annual statement data and all supplements due March 1, per the Annual
Statement Instructions. This includes all detail investment schedules and other supplements for which the Annual Statement
Instructions exempt printed detail.
The March .PDF Filing is the .pdf file for annual statement data, detail for investment schedules and supplements due March 1.
The Risk-Based Capital Electronic Filing includes all risk-based capital data.
The Risk-Based Capital.PDF Filing is the .pdf file for risk-based capital data.
The Supplemental Electronic Filing includes all supplements due April 1, per the Annual Statement Instructions.
The Supplemental.PDF Filing is the .pdf file for all supplemental schedules and exhibits due April 1.
The Quarterly Statement Electronic Filing includes the complete quarterly statement data.
The Quarterly Statement.PDF Filing is the .pdf file for quarterly statement data.
The Combined Annual Statement Electronic Filing includes the required pages of the combined annual statement and the combined
Insurance Expense Exhibit.
The Combined Annual Statement.PDF Filing is the .pdf file for the Combined annual statement data and the combined Insurance
Expense Exhibit.
The June .PDF Filing is the .pdf file for the Audited Financial Statements and Accountants Letter of Qualifications.
Column (4) Number of Copies
Indicates the number of copies that each foreign or domestic company is required to file for each type of form. The Blanks (EX) Task
Force modified the 1999 Annual Statement Instructions to waive paper filings of certain NAIC supplements and certain investment
schedule detail if such investment schedule data is available to the states via the NAIC database. The checklists reflect this action
taken by the Blanks (EX) Task Force. XXX appears in the “Number of Copies” “Foreign” column for the appropriate schedules and
exhibits. Some states have chosen to waive printed quarterly and annual statements from their foreign insurers and to rely upon
the NAIC database for these filings. This waiver could include supplemental annual statement filings. The XXX in this column
might signify that the state has waived the paper filing of the annual statement and all supplements.
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Column (5) Due Date
Indicates the date on which the company must file the form.
Column (6) Form Source
This column contains one of three words: “NAIC,” “State,” or “Company,” If this column contains “NAIC,” the company must obtain
the forms from the appropriate vendor. If this column contains “State,” the state will provide the forms with the filing instructions. If
this column contains “Company,” the company, or its representative (e.g., its CPA firm), is expected to provide the form based upon
the appropriate state instructions or the NAIC Annual Statement Instructions.
Column (7) Applicable Notes
This column contains references to the Notes to the Instructions that apply to each item listed on the checklist. The company should
carefully read these notes before submitting a filing.
w:\qa\blanks\checklists\2017 filings made in 2018\4 propcklist_2017_filingsmade2018.docx

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