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Health Entities

Click here for a printable table form of the checklist for 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 2014

(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

 

 

 

State

NAIC

State

 

 

 

 

 

I.  NAIC FINANCIAL STATEMENTS

 

 

 

 

 

 

 

1

Annual Statement (8 ½”X14”)

3

EO

2

3/1

NAIC

1

 

1.1

Printed Investment Schedule detail (Pages E01-E27)

2

EO

xxx

3/1

NAIC

 

 

2

Quarterly Financial Statement (8 ½” x 14”)

2

EO

1

5/15, 8/15, 11/15

NAIC

1

 

 

 

 

 

 

 

 

 

 

 

II.  NAIC SUPPLEMENTS

 

 

 

 

 

 

 

10

Accident & Health Policy Experience Exhibit

1

EO

1

4/1

NAIC

 

 

11

Actuarial Opinion

1

EO

1

3/1

Company

 

 

12

Health Care Exhibit (Parts 1, 2 and 3) Supplement

1

EO

1

4/1

NAIC

 

 

13

Health Care Exhibit’s Allocation Report Supplement

1

EO

1

4/1

NAIC

 

 

14

Investment Risk Interrogatories

1

EO

1

4/1

NAIC

 

 

15

Life Supplemental Data due March 1

0

EO

0

0

NAIC

 

 

16

Life Supp. Statement non-guaranteed elements –Exh.5, Int. #3

0

EO

0

3/1

Company

 

 

17

Life Supp. Statement on par/non-par policies – Exh.5, Int. 1&2

0

EO

0

3/1

Company

 

 

18

Life Supplemental Data due April 1

0

EO

0

4/1

NAIC

 

 

19

Long-term Care Experience Reporting Forms

1

EO

xxx

4/1

NAIC

 

 

20

Management Discussion & Analysis

1

EO

1

4/1

Company

 

 

21

Medicare Supplement Insurance Experience Exhibit

1

EO

xxx

3/1

NAIC

 

 

22

Medicare Part D Coverage Supplement

1

EO

1

3/1, 5/15, 8/15, 11/15

NAIC

 

 

23

Property/Casualty Supplement due March 1

0

EO

0

3/1

NAIC

 

 

24

Property/Casualty Supplement due April 1

0

EO

0

4/1

NAIC

 

 

25

Risk-Based Capital Report

1

EO

1

3/1

NAIC

 

 

26

Schedule SIS

1

N/A

N/A

3/1

NAIC

 

 

27

Supplemental Compensation Exhibit

1

N/A

N/A

3/1

NAIC

 

 

 

 

 

 

 

 

 

 

 

 

III. ELECTRONIC FILING REQUIREMENTS

 

 

 

 

 

 

 

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

Supplemental Electronic Filing

xxx

EO

xxx

4/1

NAIC

 

 

55

Supplemental  .PDF Filing

xxx

EO

xxx

4/1

NAIC

 

 

56

Quarterly Statement Electronic Filing

xxx

EO

xxx

5/15, 8/15, 11/15

NAIC

 

 

57

Quarterly .PDF  Filing

xxx

EO

xxx

5/15, 8/15, 11/15

NAIC

 

 

58

June .PDF Filing

xxx

EO

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

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V.  STATE REQUIRED FILINGS***

 

 

 

 

 

 

 

101

Advertising Certificates

1

0

1

3/1

Company

P

 

102

Annual Report Supplement (Rule 945)

1

0

1

3/1

State

P

 

103

Carrier Reporting Form

1

0

1

2/1

 State

P

 

104

Certificate of Compliance

1

0

1

3/1

State

 

 

105

Certificate of Deposit

1

0

xxx

3/1

State

P

 

106

Consumer Complaint Contact Update

1

0

1

3/1

State

P

 

107

Downstream Risk Arrangement Disclosure

1

0

1

4/1

Company

P

 

108

Exam Assessment Fee

1

0

xxx

3/1

State

C

 

109

Filings Checklist (with Column 1 completed)

1

0

1

3/1

State

 

 

110

Form B Holding Company Registration Statement

1

0

xxx

5/1

Company

H, J

 

111

Health Insurance Annual Data Report (Rule 940)1

1

0

1

4/30

State

P

 

112

Health Report Card Survey

1

0

1

3/1

State

P

  113 Long-Term Care Report (Rule 425)
1
0
1
6/30 State P

 

114

Maine Fraud and Abuse Annual 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

Premium tax

1

0

1

3/15

State

E

 

118

See Additional HMO Requirements on our website

1

0

1

3/1

State

 

 

119

Signed Jurat Page

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

1

3/1

Company

 

 

122

State Specific Enrollment Data for Maine-HMO Only

1

0

1

3/1

NAIC

 

 

123

Supplemental Health Insurance Report (Bulletin 286-A)

1

0

1

2/1

State

P

 

124

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.
***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.

 

 

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

GENERAL INSTRUCTIONS FOR COMPANIES TO USE CHECKLIST

 

Last Updated: December 3, 2013