DOMESTIC Risk Retention Captive Insurance Companies 2025 Annual and Other Filing Requirements (Due in 2026)

JOSH GREEN, M.D. GOVERNOR | KE KIAʻĀINA SYLVIA LUKE LIEUTENANT GOVERNOR | KA HOPE KIAʻĀINA STATE OF HAWAII | KA MOKUʻĀINA ʻO HAWAIʻI DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS KA ʻOIHANA PILI KĀLEPA INSURANCE DIVISION 335 MERCHANT STREET, ROOM 213, HONOLULU, HAWAII 96813 P.O. BOX 3614, HONOLULU, HAWAII 96811 Phone Number: 1-844-808-DCCA (3222) Fax Number: (808) 587-6714 cca.hawaii.gov/ins/ NADINE Y. ANDO DIRECTOR | KA LUNA HOʻOKELE SCOTT K. SAIKI INSURANCE COMMISSIONER December 31, 2025 Memorandum 2025–17C TO: DOMESTIC RISK RETENTION CAPTIVE INSURANCE COMPANIES LICENSED IN HAWAII (Formed Under Hawaii Revised Statutes § 431:19) FROM: Scott K. Saiki, Insurance Commissioner SUBJECT: DOMESTIC Risk Retention Captive Insurance Companies 2025 Annual and Other Filing Requirements (Due in 2026) CONTACT: Alan Watanabe at (808) 586-7413 or awatanab@dcca.hawaii.gov NOTE: If you are a FOREIGN Risk Retention Group, do NOT file the items on this checklist. FOREIGN Risk Retention Groups and Risk Purchasing Groups Formed Under Hawaii Revised Statutes § 431K, please contact the Certification & Agency Exam Branch at inscert@dcca.hawaii.gov. Or visit: http://cca.hawaii.gov/ins/other_ins/risk_retention_groups_foreign/ 2 I. GENERAL INFORMATION A. File documents directly with the State of Hawaii Insurance Division, Captive Insurance Branch unless otherwise noted. B. Captive insurance companies must file the required filings in electronic format, unless otherwise noted in the instructions. C. For due dates that fall on a weekend or State of Hawaii holiday, the due date is extended to the next business day. D. Postmark dates and/or e-mail received dates will be recognized in determining adherence to filing deadlines. E. Fine for late filing of the audited financial statement, statutory annual statement, quarterly statements, and other required filings of not more than $500 per day up to $10,000 per violation (HRS §§ 431:19-107 and 431:19-109). A daily fine will be levied for late filings. F. The Captive Insurance Branch has implemented OPTins (Online Premium Tax for Insurance), which will be accessible effective February 2, 2026. Captive insurance companies are encouraged to file their annual premium tax statement and make payments, including premium taxes and annual renewal fees, via OPTins. Checks are also accepted and shall be made payable to the “DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS, STATE OF HAWAII” unless otherwise noted. Refer to http://cca.hawaii.gov/ins/captive/ for latest instructions. Checks shall reference the captive insurance company name and the description of the payment. For example, “ABC Ins Co 2025 Premium Taxes” or “ABC Ins Co 2026 License Renewal Fee”. A service charge of $25 will be due for each dishonored check, and replacement checks must be certified. G. The NAIC Property/Casualty Annual and Quarterly Statement Instructions and updates are available on the NAIC website for purchase at http://content.naic.org/publications 3 II. ELECTRONIC FILING INSTRUCTIONS A. Captive insurance companies must file all required filings in electronic format and adhere to the following specifications: 1. Electronic filings shall be e-mailed to: CaptiveInsAnnualFilings@dcca.hawaii.gov 2. A Captive Insurance Manager filing electronically on behalf of clients shall send separate e-mails for each captive insurance company; 3. E-mail subject line shall include the filing year, captive insurance company name (abbreviated name acceptable), followed by the words “Annual Filings.” For example, “2025 ABC Ins Co Annual Filings”; 4. Filename of each attachment shall include the filing year, captive insurance company name, and file description. 5. File attachments shall be in SPECIFIED FILE FORMAT as indicated in column (4) of the table; 6. Each filing shall be a separate attachment (combined or merged files into one file is not allowed); 7. It is acceptable to attach more than one attachment to an e-mail provided that all attachments are for the same captive insurance company; 8. Supporting schedules may be attached to a related filing provided the filename is clearly defined. Include the filing year, captive insurance company name, related filing description, and supporting file description in the filename. 9. Contact information of the sender or person responsible for the submission shall be included in the e- mail; 10. Body of e-mail shall include text listing the attachments with brief descriptions, if not self-explanatory; 11. Password requirements and/or printing restrictions embedded in the attached files are not allowed unless pre-arranged with our Contact person; 12. Signature requirement on State of Hawaii Insurance Division forms (Form CAP-xxx) shall be replaced by typed Name and Title of duly authorized representative attesting to the accuracy and completeness of the information filed. Please also ensure the date is completed on the form; 13. For amended filings, filename shall include Amendment No. For example, “2025 ABC Ins Co CAP- 006 Amend 1”; and 14. Questions shall be directed to our Contact person, as noted in Note A, and not e-mailed to the above e- mail address. 4 RISK RETENTION CAPTIVE INSURANCE COMPANIES [LICENSED IN HAWAII] COMPANY NAME: NAIC Company Code: Contact: Telephone: REQUIRED FILINGS IN THE STATE OF: HAWAII Filings Made During the Year 2026 (1) Check- list (2) Line # (3) REQUIRED FILINGS FOR THE ABOVE STATE (4) NUMBER OF COPIES (5) DUE DATE(S) (6) FORM SOURCE* (7) APPLICABLE NOTES (A-K apply to all filings) DOMESTIC State NAIC E-Filing File Format EO I. NAIC FINANCIAL STATEMENTS 1 Annual Statement (8 ½” x 14”) N/A EO 3/1 NAIC 1.1 Printed Investment Schedule Detail (Pages E01-E30) N/A EO 3/1 NAIC 2 Quarterly Financial Statement (8 ½” x 14”) N/A EO 5/15, 8/15, 11/15 NAIC 3 Protected Cell Annual Statement PDF N/A 3/1 NAIC If applicable 4 Combined Annual Statement (8 ½” x 14”) N/A EO 5/1 NAIC If applicable II. NAIC SUPPLEMENTS 11 Accident & Health Policy Experience Exhibit N/A EO 4/1 NAIC 12 Actuarial Opinion PDF EO 3/1 Company NOTE U 13 Actuarial Opinion Summary PDF N/A 3/15 Company Report must be signed 14 Bail Bond Supplement N/A EO 3/1 NAIC 15 Combined Insurance Expense Exhibit N/A EO 5/1 NAIC 16 Credit Insurance Experience Exhibit N/A EO 4/1 NAIC 17 Cybersecurity Insurance Coverage Supplement N/A EO 4/1 NAIC If applicable 18 Director and Officer Insurance Coverage Supplement N/A EO 3/1, 5/15, 8/15, 11/15 NAIC 19 Exhibit of Other Liabilities By Lines of Business as Reported on Line 17 of the Exhibit of Premiums and Losses EO EO 3/1 NAIC 20 Financial Guaranty Insurance Exhibit N/A EO 3/1 NAIC 21 Insurance Expense Exhibit N/A EO 4/1 NAIC 22 Life, Health & Annuity Guaranty Association Assessable Premium Exhibit Parts 1 and 2 N/A N/A N/A N/A 23 Long-Term Care Experience Reporting Forms N/A N/A N/A N/A 24 Management Discussion & Analysis N/A EO 4/1 Company 25 Market Conduct Annual Statement Premium Exhibit for Year EO EO 3/1 26 Medicare Part D Coverage Supplement N/A EO 3/1, 5/15, 8/15, 11/15 NAIC 27 Medicare Supplement Insurance Experience Exhibit N/A EO 3/1 NAIC 28 Mortgage Guaranty Insurance Exhibit N/A EO 4/1 NAIC 29 Premiums Attributed to Protected Cells Exhibit N/A EO 3/1 NAIC If applicable 30 Private Flood Insurance Supplement N/A EO 4/1 NAIC 31 Reinsurance Attestation Supplement PDF EO 3/1 NAIC NOTE U 32 Exceptions to Reinsurance Attestation Supplement PDF N/A 3/1 Company 5 RISK RETENTION CAPTIVE INSURANCE COMPANIES [LICENSED IN HAWAII] COMPANY NAME: NAIC Company Code: Contact: Telephone: REQUIRED FILINGS IN THE STATE OF: HAWAII Filings Made During the Year 2026 (1) Check- list (2) Line # (3) REQUIRED FILINGS FOR THE ABOVE STATE (4) NUMBER OF COPIES (5) DUE DATE(S) (6) FORM SOURCE* (7) APPLICABLE NOTES (A-K apply to all filings) DOMESTIC State NAIC E-Filing File Format EO II. NAIC SUPPLEMENTS (continued) 33 Reinsurance Summary Supplemental N/A EO 3/1 NAIC 34 Risk-Based Capital Report PDF EO 3/1 NAIC NOTE U 35 Schedule SIS PDF N/A 3/1 NAIC 36 Supplement A to Schedule T N/A EO 3/1, 5/15, 8/15, 11/15 NAIC 37 Supplemental Compensation Exhibit N/A N/A N/A N/A 38 Supplemental Health Care Exhibit (Parts 1, and 2) N/A EO 4/1 NAIC 39 Supplemental Investment Risk Interrogatories N/A EO 4/1 NAIC . 40 Supplemental Schedule for Reinsurance Counterparty Reporting Exception – Asbestos and Pollution Contracts N/A EO 3/1 NAIC 41 Trusteed Surplus Statement N/A EO 3/1, 5/15, 8/15, 11/15 NAIC III. ELECTRONIC FILING REQUIREMENTS 61 Annual Statement Electronic Filing N/A EO 3/1 NAIC 62 March .PDF Filing N/A EO 3/1 NAIC 63 Risk-Based Capital Electronic Filing N/A EO 3/1 NAIC 64 Risk-Based Capital .PDF Filing N/A EO 3/1 NAIC 65 Combined Annual Statement Electronic Filing N/A EO 5/1 NAIC 66 Combined Annual Statement .PDF Filing N/A EO 5/1 NAIC 67 Supplemental Electronic Filing N/A EO 4/1 NAIC 68 Supplemental .PDF Filing N/A EO 4/1 NAIC 69 Quarterly Statement Electronic Filing N/A EO 5/15, 8/15, 11/15 NAIC 70 Quarterly .PDF Filing N/A EO 5/15, 8/15, 11/15 NAIC 71 June .PDF Filing N/A EO 6/1 NAIC IV. AUDIT/INTERNAL CONTROL RELATED REPORTS 81 Accountants Letter of Qualifications N/A EO 6/1 Company 82 Audited Financial Reports N/A EO 6/1 Company 83 Audited Financial Reports Exemption Affidavit N/A N/A N/A N/A 84 Communication of Internal Control Related Matters Noted in Audit N/A EO 8/1 Company NOTE S 6 RISK RETENTION CAPTIVE INSURANCE COMPANIES [LICENSED IN HAWAII] COMPANY NAME: NAIC Company Code: Contact: Telephone: REQUIRED FILINGS IN THE STATE OF: HAWAII Filings Made During the Year 2026 (1) Check- list (2) Line # (3) REQUIRED FILINGS FOR THE ABOVE STATE (4) NUMBER OF COPIES (5) DUE DATE(S) (6) FORM SOURCE* (7) APPLICABLE NOTES (A-K apply to all filings) DOMESTIC State NAIC E-Filing File Format EO IV. AUDIT/INTERNAL CONTROL RELATED REPORTS (continued) 85 Independent CPA – (change) Word or PDF N/A Prior to the commencement of the audit. See HRS § 431:3-302.5 (When applicable) Company NOTE R 86 Management's Report of Internal Control Over Financial Reporting Word or PDF N/A 8/1 Company 87 Notification of Adverse Financial Condition Word or PDF N/A When applicable Company 88 Relief from the five-year rotation requirement for lead audit partner N/A EO 3/1 Company 89 Relief from the one-year cooling off period for independent CPA N/A EO 3/1 Company 90 Relief from the Requirements for Audit Committees N/A EO 3/1 Company 91 Request to File Consolidated Audited Annual Statements Word or PDF N/A Prior to the commence- ment of the audit. Company 92 Request for Exemption to File Management’s Report of Internal Control Over Financial Reporting N/A N/A N/A N/A V. STATE REQUIRED FILINGS*** 101 Corporate Governance Annual Disclosure*** PDF 0 6/1 Company 102 Filings Checklist (with Column 1 completed) Word or PDF 0 Various State 103 Form B-Holding Company Registration Statement PDF 0 3/15 Company 104 Form F-Enterprise Risk Report **** PDF 0 3/15 Company 105 ORSA ***** PDF 0 10/15 Company 106 Premium Tax Statement (Annual Statement of Premiums Written for Taxation Purposes) for year 2025 signed on insurer’s behalf by duly authorized person. [CAP-001 Form] Excel/OPTins 0 3/1 State NOTES N & Q 107 State Filing Fees OPTins N/A Various State NOTES N & Q 108 Signed Jurat Page PDF 0 3/1, 5/15, 8/15, 11/15 NAIC NOTE G 7 RISK RETENTION CAPTIVE INSURANCE COMPANIES [LICENSED IN HAWAII] COMPANY NAME: NAIC Company Code: Contact: Telephone: REQUIRED FILINGS IN THE STATE OF: HAWAII Filings Made During the Year 2026 (1) Check- list (2) Line # (3) REQUIRED FILINGS FOR THE ABOVE STATE (4) NUMBER OF COPIES (5) DUE DATE(S) (6) FORM SOURCE* (7) APPLICABLE NOTES (A-K apply to all filings) DOMESTIC State NAIC E-Filing File Format EO V. STATE REQUIRED FILINGS (continued) 109 Group Capital Calculation (File with lead state only) Please click HERE for the latest instructions and GCC. Excel, Word or PDF 0 9/15 NAIC 110 Annual License Renewal Fee N/A 0 4/1 State NOTES N, P and Q 111 Captive Questionnaire [CAP-002 Form] Word 0 3/1 State 112 Verification of Independent Board of Director/SAC Member** [CAP-008 Form] Word or PDF 0 6/1 State NOTE V 113 Economic Impact Report (report expenses on accrual basis) [CAP-003 Form] Excel 0 3/1 State 114 Insurance Holding Company System • Form B - Annual Registration Statement PDF 0 3/15 Company • Form C - Summary of Changes to Registration Statement PDF 0 3/15 Company • Form F - Enterprise Risk Report*** Word or PDF 0 3/15 Company or Disclaimer of Affiliation Word or PDF 0 3/15 Company If you file a Disclaimer of Affiliation, submit this Disclaimer with all states that you are licensed and/or registered. Forms B, C and F are located at: http://cca.hawaii.gov/ins/har/ HAR Chapter 14 – Insurance Holding Company System 115 Statutory Compliance Report [CAP-006 Form] Excel 0 3/1 State 116 Financial Projections Excel 0 6/1 Company NOTE T 8 RISK RETENTION CAPTIVE INSURANCE COMPANIES [LICENSED IN HAWAII] COMPANY NAME: NAIC Company Code: Contact: Telephone: REQUIRED FILINGS IN THE STATE OF: HAWAII Filings Made During the Year 2026 (1) Check- list (2) Line # (3) REQUIRED FILINGS FOR THE ABOVE STATE (4) NUMBER OF COPIES (5) DUE DATE(S) (6) FORM SOURCE* (7) APPLICABLE NOTES (A-K apply to all filings) DOMESTIC State NAIC E-Filing File Format EO V. STATE REQUIRED FILINGS (continued) 117 Insured Vehicle Census Report for the Quarter Ended 12/31/25 OPTins 0 2/15 Company Required to be submitted via OPTins for Captives authorized to write DIRECT MOTOR VEHICLE insurance in Hawaii Refer to Insurance Commissioner’s Memorandum 2017-8R available on our website at: http://cca.hawaii.gov/ins/insurers/rate_policy/mv_forms/ Property & Casualty Annual Filing Instructions (refer to Line Item #116) available at: http://cca.hawaii.gov/ins/insurers/annual-filing-instructions-and-tax-forms/ 118 Drivers’ Education Fund Underwriters’ Fee OPTins 0 2/15 Company Required to be submitted via OPTins for Captives authorized to write DIRECT MOTOR VEHICLE insurance in Hawaii Refer to Insurance Commissioner’s Memorandum 2017-8R available on our website at: http://cca.hawaii.gov/ins/insurers/rate_policy/mv_forms/ Property & Casualty Annual Filing Instructions (refer to Line Item #112) available at: http://cca.hawaii.gov/ins/insurers/annual-filing-instructions-and-tax-forms/ 119 Annual Assessment for Workers’ Compensation Insurance Special Compensation Fund on behalf of the Department of Labor & Industrial Relations (DLIR) Not available 0 N/A State DLIR (Required for Captives authorized to write DIRECT WORKERS’ COMPENSATION insurance in HAWAII) [ref. HRS § 386:151 & HRS § 386:152] [Check payable to Department of Labor & Industrial Relations, State of Hawaii] Please mail DIRECTLY to: Department of Labor & Industrial Relations Disability Compensation Division P. O. Box 3769 Honolulu, HI 96812-3769 120 Auditor’s Communication with Those Charged with Governance (SAS 114 Letter) PDF 0 8/1 Company 9 RISK RETENTION CAPTIVE INSURANCE COMPANIES [LICENSED IN HAWAII] COMPANY NAME: NAIC Company Code: Contact: Telephone: REQUIRED FILINGS IN THE STATE OF: HAWAII Filings Made During the Year 2026 (1) Checklist (2) Line # (3) REQUIRED FILINGS FOR THE ABOVE STATE (4) NUMBER OF COPIES (5) DUE DATE(S) (6) FORM SOURCE* (7) APPLICABLE NOTES DOMESTIC State NAIC (A-K apply to all filings) E-Filing File Format EO V. STATE REQUIRED FILINGS (continued) 121 Data Security Annual Certification Form EO 0 3/15 State Note O 122 Information Security Program Exemption Certification Form EO 0 3/15 State Note O * 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 Corporate Governance Annual Disclosure Model Act, an annual disclosure is required of all insurers or insurance groups by June 1. The Corporate Governance Annual Disclosure is a state filing only and should not be submitted by the company to the NAIC. Note however that this filing is intended to be submitted to the lead state if filed at the insurance group level. For more information on lead states, see the following NAIC URL: http://www.naic.org/public_lead_state_report.htm **** 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. Note however that this filing is intended to be submitted to the lead state. For more information on lead states, see the following NAIC URL: http://www.naic.org/public_lead_state_report.htm ***** For those states that have adopted the NAIC Risk Management and Own Risk and Solvency Assessment Model Act, a summary report is required annually by insurers and insurance groups above a specified premium threshold. The ORSA Summary Report is a state filing only and should not be submitted by the company to the NAIC. Note however that this filing is intended to be submitted to the lead state if filed at the insurance group level. For more information on lead states, see the following NAIC URL: http://www.naic.org/public_lead_state_report.htm 10 NOTES AND INSTRUCTIONS (A-K APPLY TO ALL FILINGS) [RISK RETENTION CAPTIVE INSURANCE COMPANIES] A Required Filings Contact Person: Annual Statement and all filings: Alan Watanabe: (808) 586-7413 Fax: (808) 586-0987 E-Mail: awatanab@dcca.hawaii.gov B Mailing Address: State of Hawaii, DCCA, Insurance Division ATTN: CAPTIVE INSURANCE BRANCH P. O. Box 3614 Honolulu, HI 96811-3614 OR State of Hawaii, DCCA, Insurance Division ATTN: CAPTIVE INSURANCE BRANCH 335 Merchant Street, Room 213 Honolulu, HI 96813 C Mailing Address for Filing Fees: N/A – no filing fees D Mailing Address for Premium Tax Payments: Same as Note B E Delivery Instructions: All filings must be RECEIVED ELECTRONICALLY or 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: Fine for late filings. Captives are subject to a fine for filing past the due date of not more than $500 per day up to $10,000 per violation (HRS §§ 431:19-107 and 431:19-109). A daily fine will be levied for late filings. G Original Signatures: The Annual and Quarterly Statement Jurat pages shall include signatures of at least two of the insurer’s principal officers. Original signatures must be manually signed by the appropriate corporate officers and be properly notarized. H Not Used: N/A NOTES AND INSTRUCTIONS (A-K APPLY TO ALL FILINGS) [RISK RETENTION CAPTIVE INSURANCE COMPANIES] (Continued) I Amended Filings: Amended items must be accompanied by an explanation of the amendments. If there are signature requirements for the original filing, the same should be followed for any amendment. If filing is e-filed with the NAIC, the State of Hawaii Insurance Division should be notified and the reason for the amendment. J Exceptions from normal filings: If applicable. K Bar Codes (State or NAIC): N/A for all Hawaii filings. L Signed Jurat: Domestic Insurers – See Note G for Jurat Page requirements. M NONE Filings: See NAIC Annual Statement Instructions. 11 NOTES AND INSTRUCTIONS (A-K APPLY TO ALL FILINGS) [RISK RETENTION CAPTIVE INSURANCE COMPANIES] N Filings new, discontinued or modified materially since last year: New Filings: None Discontinued Filings: None. Modified Materially: #106 Premium Tax Statement [CAP-001 Form] – RRGs with premiums written in the State of Hawaii are required to file this form via OPTins. Refer to http://cca.hawaii.gov/ins/captive/ for latest instructions. #110 Annual License Renewal Fee – payment accepted via OPTins. Refer to http://cca.hawaii.gov/ins/captive/ for latest instructions. # O Electronic Filing: Column (4) NAIC Electronic filing is intended to be filing(s) submitted to the NAIC via the NAIC Internet Filing Site. Please review General Instructions for Companies to Use Filings Checklist. Column (4) STATE electronic filing shall be e-mailed to CaptiveInsAnnualFilings@dcca.hawaii.gov. Data Security Law Annual Certification Form and Data Security Law Exemption Certification Form can be downloaded at https://cca.hawaii.gov/ins/insurance-data-security-law/ P Annual License Renewal Fee: (Line #110) $500.00 due on April 1, 2026. Q Checks/payments: OPTins #106 Premium Tax – payment accepted via OPTins. #110 Annual License Renewal Fee – payment accepted via OPTins. Updates on OPTins to be posted on http://cca.hawaii.gov/ins/captive/ Checks should be made payable to: “DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS, STATE OF HAWAII” or “DCCA, STATE OF HAWAII” unless otherwise noted on the form. A service charge of $25 will be assessed for each dishonored check. Your cancelled check is your receipt; an official receipt will be issued only upon written request. 12 NOTES AND INSTRUCTIONS (A-K APPLY TO ALL FILINGS) [RISK RETENTION CAPTIVE INSURANCE COMPANIES] R Independent CPA: (Line #85) Required when a change in independent CPA occurs. Letter stating that the independent CPA is aware of the provisions of the insurance statutes and rules that relate to accounting and financial matters of the State of Hawaii in accordance with whose regulation the audited financial report is made and affirming that the independent CPA will express an opinion on the financial statements in terms of their conformity to the statutory accounting practices prescribed or otherwise permitted by the State of Hawaii Insurance Division, specifying such exceptions the independent CPA may believe appropriate. S Communication of Internal Control Related Matters Noted in Audit: (Line #84) HAR Section 16-185-110 requires written communication of unremediated material weaknesses noted during the audit within 60 days of filing the audited financial report. The communication should state if no unremediated material weaknesses were noted. T Financial Projections (Line #116) Please e-mail electronic copy (Excel only) to CaptiveInsAnnualFilings@dcca.hawaii.gov on June 1: Financial Projections (Actual 2025 and Budget 2026-2028) • 2025 Budget to Actual Comparison with explanations for variances equal to or greater than 20%. • Briefly describe the underwriting policy and pricing methodology . • 2026-2028 Financial projections with underlying assumptions. U Signature Page for NAIC Supplements filed with the State The signature page of the following NAIC Supplements must be filed in electronic format with the State, if the signature(s) are not included on the NAIC submission: • Actuarial Opinion (Line #12) • Reinsurance Attestation Supplement, with 2 signatures (Line #31) • Risk-Based Capital Report, with 2 signatures (Line #34) V Verification of Independent Board of Director/SAC Member [CAP-008 Form] Pursuant to HRS § 431K-2(c)(1), the risk retention group must submit its record of the determination of a director/SAC member’s independence to the commissioner annually. The risk retention group (“RRG”) shall submit its record of determination as the company deems appropriate OR opt to submit this form annually to satisfy the requirement. This form is OPTIONAL and was created to assist the RRG in recording the determination of a director/SAC member’s independence. W Website: Please visit the following website for additional information: http://cca.hawaii.gov/ins/captive/ 13 STATE OF HAWAII Domestic Risk Retention Captive Insurance Companies Licensed in Hawaii General Instructions for Companies to Use Filings Checklist Please Note: This state’s instructions for companies to file with the NAIC are included in this Filings Checklist. The NAIC will not be sending their own checklist. Electronic filing is intended to be filing(s) submitted to the NAIC via the NAIC Internet Filing Site. Companies are not required to file hard copy filings with the NAIC. When a filing is made with the NAIC, the document is considered filed with the Commissioner when the filing is accepted by the NAIC. Any filings which are not required to be filed with the NAIC shall be filed directly with the State of Hawaii Insurance Division. Documents submitted to the State of Hawaii Insurance Division which are not required to be filed (not on the Filings Checklist) will be destroyed without review. Documents filed with the NAIC which are not required to be filed shall not be accepted by the NAIC. Column (1) (Checklist) Companies must use the filings checklist and place an “X” in this column when submitting information to the state. The checklist is now required for all state filings. 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 NAIC Annual Statement Instructions. This includes all detail investment 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 Supplemental Electronic Filing includes all supplements due April 1, per the NAIC Annual Statement Instructions. The Supplemental .PDF Filing is the .pdf file for all supplemental schedules and exhibits due April 1. The Quarterly Statement Electronic Filing includes the complete quarterly statement data. The Quarterly Statement .PDF Filing is the .pdf file for quarterly statement data. The Combined Annual Statement Electronic Filing includes the required pages of the combined annual statement and the combined Insurance Expense Exhibit. The Combined Annual Statement .PDF Filing is the .pdf file for the combined annual statement data and the combined Insurance Expense Exhibit. The June .PDF Filing is the .pdf file for the Audited Financial Statements and Accountants Letter of Qualifications. 14 Column (4) (Number of Copies) Indicates the electronic filing format that each domestic Risk Retention Captive Insurance Company is required to file for each type of form. 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 either with the filing instructions OR will be mailed to the insurer at a later date. 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. Questions shall be directed to the contact person in Note A.