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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 2009
(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 XXX 4/1 NAIC  
  11 Actuarial Certification Related Annuity Nonforfeiture Compliance XXX EO XXX 3/1 Company  
  12 Actuarial Opinion on X-Factors XXX EO XXX 3/1 Company  
  13 Actuarial Opinion on Separate Accounts Funding XXX EO XXX 3/1 Company  
  14 Actuarial Opinion on Synthetic Guaranteed Investment Contracts XXX EO XXX 3/1 Company  
  15 Interest Sensitive Life Insurance Products Report XXX EO XXX 4/1 NAIC  
  16 Investment Risk Interrogatories XXX EO XXX 4/1 NAIC  
  17 Long Term Care Experience Reporting Forms XXX EO XXX 4/1 NAIC  
  18 Management Discussion & Analysis XXX EO XXX 4/1 Company  
  19 Medicare Supplement Insurance Experience Exhibit XXX EO XXX 3/1 NAIC  
  20 Medicare Part D Coverage Supplement XXX EO XXX 3/1, 5/15, 8/15, 11/15 NAIC  
  21 Reasonableness of Assumptions Certification XXX EO XXX 3/1, 5/15, 8/15, 11/15 Company  
  22 Reasonableness & Consistency of Assumptions Cert. XXX EO XXX 3/1, 5/15, 8/15, 11/15 Company  
  23 Reasonableness of Assumptions Cert. for Implied Guaranteed Rate Method XXX EO XXX 3/1, 5/15, 8/15, 11/15 Company  
  24 Reasonableness & Consistency of Assumptions Cert. (Updated Average Market Value) XXX EO XXX 3/1, 5/15, 8/15, 11/15 Company  
  25 Reasonableness & Consistency of Assumptions Cert. (Updated Market Value) XXX EO XXX 3/1, 5/15, 8/15, 11/15 Company  
  26 Risk-Based Capital Report XXX N/A XXX 3/1 NAIC  
  27 RBC Certification required under C-3 Phase I XXX N/A XXX 3/1 Company  
  28 RBC Certification required under C-3 Phase II XXX N/A XXX 3/1 Company  
  29 Statement of Actuarial Opinion XXX EO XXX 3/1 Company  
  30 Statement on non-guaranteed elements – Exhibit 5 Interr. #3 XXX EO XXX 3/1 Company  
  31 Statement on participating/non-participating policies – Exhibit 5 Inter. #1 XXX EO XXX 3/1 Company  
  32 Supplemental Compensation Exhibit XXX N/A N/A 3/1 NAIC O
  33 Trusteed Surplus Statement XXX EO XXX 3/1, 5/15, 8/15, 11/15 NAIC  
    III. ELECTRONIC FILING REQUIREMENTS            
  40 Annual Statement Electronic Filing XXX 1 XXX 3/1 NAIC  
  41 March .PDF Filing XXX 1 XXX 3/1 NAIC  
  42 Separate Accounts Electronic Filing XXX 1 XXX 3/1 NAIC  
  43 Separate Accounts .PDF Filing XXX 1 XXX 3/1 NAIC  
  44 Supplemental Electronic Filing XXX 1 XXX 4/1 NAIC  
  45 Supplemental .PDF Filing XXX 1 XXX 4/1 NAIC  
  46 Quarterly Statement Electronic Filing XXX 1 XXX 5/15, 8/15 & 11/15 NAIC  
  47 Quarterly .PDF Filing XXX 1 XXX 5/15, 8/15 & 11/15 Company  
  48 June .PDF Filing XXX 1 XXX 6/1 NAIC  
    IV. AUDITED FINANCIAL STATEMENTS            
  61 Accountants Letter of Qualifications XXX N/A N/A 6/1 Company  
  62 Audited Financial Statements

XXX

EO

XXX

 6/1 Company  
  63 Audited Financial Statements Exemption Affidavit XXX N/A N/A 6/1 Company  
  64 Independent CPA XXX N/A N/A 6/1 Company  
  65 Notification of Adverse Financial Condition XXX N/A N/A 6/1 Company  
  66 Report of Significant Deficiencies in Internal Controls XXX N/A N/A 6/1 Company  
  67 Request for Exemption to File XXX N/A 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) 1 0 1 3/1 State O
  104 Carrier Reporting Form 1 0 1 2/1 State O
  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 O
  109 Mandated Benefit Expense Report (Bulletin 292) 1 0 1 4/30 State O
  110 Premium Tax XXX 0 1 3/15 State D, O
  111 Signed Jurat XXX 0 XXX 3/1, 5/15, 8/15, 11/15 NAIC  
  112 State Filing Fees XXX XXX 1 8/10 State C, O
  113 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: Lauri Cooper (207) 624-8464 Laurelyn.S.Cooper@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
124 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/2008.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 filing 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 .pdf files for annual statement data, detail for investment schedules and supplements due March 1.

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 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 supplements 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.

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 (E) 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: January 2, 2009