Skip First Level Navigation | Skip All Navigation

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

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 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") 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" x 14") 2 EO XXX 3/1 NAIC I
    II. NAIC SUPPLEMENTS            
  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 Certifications 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 4/1 NAIC  
  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 3/1 Company  
  23 Financial Officer Certification Related to Clearly Defined Hedging Strategy required by Actuarial Guideline XLIII 1 EO XXX 4/1 NAIC  
  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 XXX 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 3/1 Company  
  31 Management Certification that the Valuation Reflects Management’s Intent required by Actuarial Guideline XLIII 1 EO XXX 4/1 Company  
  32 Management Discussion & Analysis 1 EO XXX 3/1 NAIC  
  33 Medicare Supplement Insurance Experience Exhibit 1 EO XXX 3/1, 5/15, 8/15, 11/15 NAIC  
  34 Medicare Part D Coverage Supplement 1 EO XXX 3/1, 5/15, 8/15, 11/15 Company  
  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 NAIC  
  40 Risk-Based Capital Report 1 EO XXX 3/1 Company  
  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 N/A N/A 3/1 NAIC  
  43 Schedule SIS 1 EO XXX 3/1 Company  
  44 Statement on non-guaranteed elements - Exhibit 5 Int. #3 1 EO XXX 3/1 Company  
  45 Statement on par/non-par policies – Exhibit 5 Int. 1&2 1 N/A N/A 3/1 NAIC  
  46 Supplemental Compensation Exhibit 1 EO XXX 3/1 NAIC P
  47 Supplemental Schedule O 1 EO XXX 3/1, 5/15, 8/15, 11/15 NAIC  
  48 Trusteed Surplus Statement 1 EO XXX 3/1 NAIC  
  49 Workers’ Compensation Carve Out Supplement 1 EO XXX 3/1 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 Accounts .PDF 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 NAIC  
  60 June .PDF Filing XXX 1 XXX 6/1 NAIC  
    IV. AUDIT/INTERNAL CONTROL RELATED REPORTS            
  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 6/1 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 6/1 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 6/1 Company  
  78 Request for Exemption to File 1 N/A N/A 3/1 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 Committee 1 EO N/A 3/1 Company  
    V. STATE REQUIRED FILINGS            
  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 0 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 Annual Report 1 0 1 3/1 State P
  115 Managing General Agent Report 1 0 1 3/1 State P
  116 Mandated Benefit Experience Report (Bulletin 292) 1 0 1 4/30 State P
  117 Premium Tax 1 0 1 3/15 State E
  118 Signed Jurat Page 1 XXX XXX 3/1, 5/15, 8/15, 11/15 NAIC  
  119 State Filing Fees 1 0 1 8/10 State C, P
  120 State Page for Maine 1 0 XXX 3/1 Company  
  121 Supplemental Health Insurance Report (Bulletin 286A) 1 0 1 4/1 State P
  122 Tick Borne Disease Report 1 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: January 10, 2012