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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 2010
(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 G, J
  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 G, J
  3 Separate Accounts Annual Statement (8 ½" x 14") 2 EO XXX 3/1 NAIC G, J
    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 Opinion on X-Factors 1 EO XXX 3/1 Company  
  13 Actuarial Opinion on Separate Accounts Funding 1 EO XXX 3/1 Company  
  14 Actuarial Opinion on Synthetic Guaranteed Investment Contracts 1 EO XXX 3/1 Company  
  15 Credit Insurance Experience Exhibit 1 EO XXX 4/1 NAIC  
  16 Interest Sensitive Life Insurance Products Report 1 EO XXX 4/1 NAIC  
  17 Investment Risk Interrogatories 1 EO XXX 4/1 NAIC  
  18 Life, Health & Annuity Guaranty Assessment Base
Reconciliation Exhibit		 1 EO XXX 4/1 NAIC  
  19 Life, Health & Annuity Guaranty Assessment Base Reconciliation Exhibit Adjustment Form 1 EO XXX 4/1 NAIC  
  20 Long-term Care Experience Reporting Forms 1 EO XXX 4/1 NAIC  
  21 Management Discussion & Analysis 1 EO XXX 4/1 Company  
  22 Medicare Supplement Insurance Experience Exhibit 1 EO XXX 3/1 NAIC  
  23 Medicare Part D Coverage Supplement 1 EO XXX 3/1, 5/15, 8/15, 11/15 NAIC  
  24 Reasonableness of Assumptions Certification 1 EO XXX 3/1, 5/15, 8/15, 11/15 Company  
  25 Reasonableness & Consistency of Assumptions Cert. 1 EO XXX 3/1, 5/15, 8/15, 11/15 Company  
  26 Reasonableness of Assumptions Cert. for Implied Guaranteed Rate Method 1 EO XXX 3/1, 5/15, 8/15, 11/15 Company  
  27 Reasonableness & Consistency of Assumptions Cert. (Updated Average Market Value) 1 EO XXX 3/1, 5/15, 8/15, 11/15 Company  
  28 Reasonableness & Consistency of Assumptions Cert. (Updated Market Value) 1 EO XXX 3/1, 5/15, 8/15, 11/15 Company  
  29 Risk-Based Capital Report 1 EO XXX 3/1 NAIC  
  30 RBC Certification required under C-3 Phase I 1 EO XXX 3/1 Company  
  31 RBC Certification required under C-3 Phase II 1 EO XXX 3/1 Company  
  32 Schedule SIS 1 N/A N/A 3/1 NAIC  
  33 Statement of Actuarial Opinion 1 EO XXX 3/1 Company  
  34 Statement on non-guaranteed elements - Exhibit 5 Int. #3 1 EO XXX 3/1 Company  
  35 Statement on par/non-par policies – Exhibit 5 Int. 1.1 1 EO XXX 3/1 Company  
  36 Supplemental Compensation Exhibit 1 N/A N/A 3/1 NAIC O
  37 Supplemental Schedule O 1 EO XXX 3/1 NAIC  
  38 Trusteed Surplus Statement 1 EO XXX 3/1, 5/15, 8/15, 11/15 NAIC  
  39 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. AUDITED FINANCIAL STATEMENTS            
  71 Accountants Letter of Qualifications 1 EO N/A 6/1 Company  
  72 Audited Financial Statements 1 EO XXX 6/1 Company  
  73 Audited Financial Statements Exemption Affidavit 1 N/A N/A 6/1 Company  
  74 Independent CPA 1 N/A N/A 6/1 Company  
  75 Notification of Adverse Financial Condition 1 N/A N/A 6/1 Company  
  76 Report of Significant Deficiencies in Internal Controls 1 N/A N/A 6/1 Company  
  77 Request for Exemption to File 1 N/A N/A 5/1 Company  
    V. STATE REQUIRED FILINGS            
  101 Advertising Certificate 1 0 1 3/1 Company O
  102 Affidavit of Filing 0 0 N/A 3/1 State  
  103 Annual Report Supplement (Rule 945) 1 0 1 3/1 State O
  104 Carrier Reporting Form 1 0 1 2/1 State O
  105 Certificate of Compliance 1 0 XXX 3/1 State  
  106 Certificate of Deposit 1 0 XXX 3/1 State O
  107 Certificate of Valuation 1 0 XXX 3/1 State  
  108 Consumer Complaint Contact Update 1 0 1 3/1 State O
  109 Exam Assessment Fee 1 0 0 3/1 State C
  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 I
  112 Health Insurance Annual Data Report (Rule 940) 1 0 1 4/30 State O
  113 Health Report Card Survey 1 0 1 3/1 State O
  114 Maine Fraud and Abuse Annual Report 1 0 1 3/1 State O
  115 Managing General Agent Report 1 0 1 3/1 State O
  116 Mandated Benefit Experience Report (Bulletin 292) 1 0 1 4/30 State O
  117 Premium Tax 1 0 1 3/15 State D
  118 Signed Jurat 1 XXX XXX 3/1, 5/15, 8/15, 11/15 NAIC L
  119 State Filing Fees 1 0 1 8/10 State C, O
  120 State Page for Maine 1 0 XXX 3/1 Company  
  121 Supplemental Health Insurance Report (Bulletin 286A) 1 0 1 4/1 State O

 

*If XXX appears in this column, this state does not require this filing, if the data is filed electronically with the NAIC and in accordance to the guidelines of the domiciliary state. 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)
A Required Filings Contact Person:

Annual and Quarterly Statements:
Foriegn Companies: Lauri Cooper 207-624-8464 Laurelyn.S.Cooper@maine.gov
Domestic Companies: Nichole Bilodeau 207-624-8592 Nichole.L.Bilodeau@maine.gov
B Mailing Address: Regular Mail:
Maine Bureau of Insurance
Financial Analysis Division
#34 State House Station
Augusta, ME 04333-0034		 Courier:
Maine Bureau of Insurance
Financial Analysis Division
76 Northern Avenue
Gardiner, ME 04345
C Mailing Address for Filing Fees: Annual Statement filing fees will be billed on or before July 1 of each year. DO NOT send fees at this time.
If the domestic company has elected to pay examination assessment fees based on Title 24-A, M.R.S.A., § 228 (3), please include your payment with the filing of your annual statement. If you have any questions with regards to the exam fees, please contact Stuart Turney 207-624-8468 or Email Stuart.E.Turney@maine.gov
D Mailing Address & Contact for Premium Tax Payments, Questions & Forms: Maine Revenue Services, PO Box 9120, Augusta, ME 04333-9120, Phone: Carlotta Larrabee 207-624-9753.
http://www.maine.gov/revenue/forms/insurance/2009.htm
E Delivery Instructions: All filings must be postmarked no later than the indicated due date. If the due date falls on a weekend or holiday, then the deadline is extended to the next business day.
F Late Filings: Foreign companies must supply a written copy of any exemption or extension received by its state of domicile at least 10 days prior to the filing due date to receive such from Maine. Domestic companies should apply at least 30 days prior to the due date.
G Original Signatures: Original signatures required on all filings from Domestic Companies. Foreign companies should follow the instructions in the NAIC Annual Statement instructions.
H Signature/Notarization/Certification: The following officers are required to sign the annual statement: CEO, President, & Treasurer for domestic companies.
I Amended Filings:

The following items must be filed within 10 days of their amendment, along with an explanation of the amendments.
*Bylaws (certified) $25.00 filing fee, *Articles $25.00 filing fee, *Biographical Affidavits(domestics only)
Domestic Form B Statements are Due 5/1. Form B Holding Company Registration Statement amendments are due on the 15th of the month following the change.

CHECK PAYABLE TO TREASURER STATE OF MAINE

*As changes occur.
J Exceptions from normal filings:
  • Foreign companies must supply a written copy of any exemption or extension received by its state of domicile at least 10 days prior to the filing due date to receive such from Maine. Domestic companies should apply at least 30 days prior to the due date.
  • Foreign or alien insurers are only required to file an Annual Statement at the request of the Superintendent of Insurance.
K Bar Codes (State or NAIC) Not Used
L Signed Jurat Signed Jurat pages are NOT required for foreign or alien insurers. They are required for domestic insurers.
M NONE Filings: Supplemental exhibits & schedules as listed in the annual statement interrogatories are not required to be filed if your response in the supplemental exhibits & schedules interrogatories is a "NONE" report.
N Filings new, discontinued, modified since last year:

None
O Required by the State of Maine
Should be filed separately from the annual statement
 

 

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 include filing via the Internet or via diskette with the NAIC. Companies that file with the NAIC via the Internet are not required to submit diskettes 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 investments 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 Separate Accounts Electronic Filing includes the separate accounts annual statement and investment schedule detail.

The Separate Accounts .PDF Filing is the .pdf file for the separate accounts annual statement and all investment schedule detail.

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 Electronic Filing includes the quarterly statement data.

The Quarterly .PDF Filing is the .pdf for quarterly statement data.

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 (E) 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 (EX4) 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.

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 (generally, on its website). 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.

Last Updated: November 19, 2009