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

Property & Casualty Insurers

Click here for a printable table form of the checklist for Property & Casualty 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  
  1.1 Printed Investment Schedule detail (Pages E01-E27) 1 EO XXX 3/1 NAIC I
  2 Quarterly Financial Statement (8 ½" x 14") 1 0 XXX 5/15, 8/15, 11/15 NAIC  
  3 Protected Cell Annual Statement 1 EO XXX 5/1 NAIC  
  4 Combined Annual Statement (8 ½” x 14”) 2 EO XXX 5/1 NAIC I
    II. NAIC SUPPLEMENTS            
  10 Accident & Health Policy Experience Exhibit 1 EO XXX 4/1 NAIC  
  11 Actuarial Opinion 1 EO XXX 3/1 Company  
  12 Actuarial Opinion Summary 1 N/A XXX 3/15 Company  
  13 Bail Bond Supplement 1 EO XXX 3/1 NAIC  
  14 Combined Insurance Expense Exhibit 1 EO XXX 5/1 NAIC  
  15 Credit Insurance Experience Exhibit 1 EO XXX 4/1 NAIC  
  16 Director and Officer Insurance Coverage Supplement 1 EO XXX 5/15, 8/15, 11/15 NAIC P
  17 Exceptions to Reinsurance Attestation Supplement 1 N/A XXX 3/1 Company  
  18 Financial Guaranty Insurance Exhibit 1 EO XXX 3/1 NAIC  
  19 Health Care Exhibit (Parts 1, 2 and 3) Supplement 1 EO XXX 4/1 NAIC  
  20 Health Care Exhibit’s Allocation Report Supplement 1 EO XXX 4/1 NAIC  
  21 Investment Risk Interrogatories 1 EO XXX 4/1 NAIC  
  22 Insurance Expense Exhibit 1 EO XXX 4/1 NAIC  
  23 Long Term Care Experience Reporting Forms 1 EO XXX 4/1 NAIC  
  24 Management Discussion & Analysis 1 EO XXX 4/1 Company  
  25 Medicare Supplement Insurance Experience Exhibit 1 EO XXX 3/1 NAIC  
  26 Medicare Part D Coverage Supplement 1 EO XXX 3/1, 5/15, 8/15, 11/15 NAIC  
  27 Premiums Attributed to Protected Cells Exhibit 1 EO XXX 3/1 NAIC  
  28 Reinsurance Attestation Supplement 1 EO XXX 3/1 Company  
  29 Reinsurance Summary Supplemental 1 EO XXX 3/1 NAIC  
  30 Risk-Based Capital Report 1 EO XXX 3/1 NAIC  
  31 Schedule SIS 1 N/A N/A 3/1 NAIC  
  32 Supplement A to Schedule T 1 EO XXX 3/1, 5/15, 8/15, 11/15 NAIC  
  33 Supplemental Compensation Exhibit 1 N/A N/A 3/1 NAIC P
  34 Trusteed Surplus Statement 1 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 Combined Annual Statement Electronic Filing XXX 1 XXX 5/1 NAIC  
  55 Combined Annual Statement .PDF Filing XXX 1 XXX 5/1 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   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 6/1 Company  
  78 Request for Exemption to File 1 N/A N/A 6/1 Company  
  79 Request to File Consolidated Audited Annual Statements 1 N/A N/A 6/1 Company  
  80 Relief from the five-year rotation requirement for lead audit partner 1 N/A N/A 6/1 Company  
  81 Relief from the one-year cooling off period for independent CPA 1 EO N/A 6/1 Company  
  82 Relief from the Requirements for Audit Committees 1 EO N/A 6/1 Company  
                 
    V. STATE REQUIRED FILINGS            
  101 Annual Report Supplement (Rule 945) 1 0 1 3/1 State P
  102 Carrier Reporting Form 1 0 1 2/1 State P
  103 Certificate of Compliance 1 0 XXX 3/1 State  
  104 Certificate of Deposit 1 0 XXX 3/1 State P
  105 Consumer Complaint Contact Update 1 0 1 3/1 State P
  106 Exam Assessment Fee 1 0 XXX 3/1 State C,D
  107 Filings Checklist (with Column 1 completed) 1 0 XXX 3/1 State  
  108 Form B Holding Company Registration Statement 1 0 XXX 5/1 Company H,J
  109 Liquor Liability Report 1 0 1 3/1 State P
  110 Maine Fraud and Abuse Annual Report 1 0 1 3/1 State P
  111 Managing General Agent Report 1 0 1 3/1 Company P
  112 Mandated Benefit Experience Report (Bulletin 292) 1 0 1 4/30 State P
  113 Premium Tax 1 0 1 3/15 State E
  114 Signed Jurat Page 1 0 XXX 3/1, 5/15, 8/15, 11/15 NAIC  
  115 State Filing Fees 1 XXX 1 8/10 State C, P
  116 State of Maine Page 1 0 XXX 3/1 Company  
  117 Supplemental Health Insurance Report (Bulletin 286A) 1 0 1 4/1 State P
  118 Tick-Borne Disease Report 1 0 1 2/1 State P
  119 Workers Compensation Benefits Report 1 0 1 3/1 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 18, 2012