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Maine.gov > PFR Home > Insurance Regulation > Company Services > Annual Statement Filing > Checklists

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 2012
(1)

Check-list

(2)

Line
#

(3)

REQUIRED FILINGS FOR THE ABOVE STATE

 (4)

NUMBER OF COPIES*

(5)

DUE DATE
Postmarked

(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 Certifications 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 1 XXX 3/1 NAIC  
  51 March .PDF Filing XXX 1 XXX 3/1 NAIC  
  52 Risk-Based Capital Electronic Filing XXX 1 N/A 3/1 NAIC  
  53 Risk Based Capital .PDF Filing XXX 1 N/A 3/1 NAIC  
  54 Separate Accounts Electronic Filing XXX 1 XXX 3/1 NAIC  
  55 Separate AccountsPDF Filing XXX 1 XXX 3/1 NAIC  
  56 Supplemental Electronic Filing XXX 1 XXX 4/1 NAIC  
  57 Supplemental .PDF Filing XXX 1 XXX 4/1 NAIC  
  58 Quarterly Statement Electronic Filing XXX 1 XXX 5/15, 8/15 & 11/15 NAIC  
  59 Quarterly .PDF Filing XXX 1 XXX 5/15, 8/15 & 11/15    
  60 June .PDF Filing XXX 1 XXX 6/1 NAIC  
    IV. AUDITED/INTERNAL CONTROL RELATED REPORTS            
  71 Accountants Letter of Qualifications XXX EO N/A 6/1 Company  
  72 Audited Financial Reports

XXX

EO

N/A

 6/1 Company  
  73 Audited Financial Reports Exemption Affidavit XXX N/A N/A 6/1 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 6/1 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 6/1 Company  
  78 Request for Exemption to File XXX N/A N/A 6/1 Company  
  79 Relief from the five-year rotation requirement for lead audit partner XXX N/A N/A 5/1 Company  
  80 Relief from the one-year cooling off period for independent CPA XXX EO N/A 6/1 Company  
  81 Relief from the Requirements for Audit Committees XXX EO N/A 6/1 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 (Rule 945) 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 Page 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 286A) XXX 0 1 4/1 State P
  114 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.

 

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

GENERAL INSTRUCTIONS FOR COMPANIES TO USE CHECKLIST

 

Last Updated: September 27, 2010