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STATE OF HAWAII INSURANCE DIVISION • P. 0. BOX 3614, HONOLULU, HI 96811-3614 HEAL TH ENTITIES (LICENSED IN HAWAII) 335 MERCHANT STREET, 2No FLOOR, HONOLULU, HI 96813 ATTN: HEALTH BRANCH • ATTACHMENT Memorandum 2003-11H December12,2003 COMPANY NAME: ____________________ NAIC Company Code: ---------- Contact: Telephone:-------------- REQUIRED FILINGS IN THE STATE OF HAWAII DURING THE YEAR 2004 (1) (2) (3) (4) (5) (6) (7) Check- Line NUMBER OF FORM APPLICABLE list # REQUIRED FILINGS FOR HAWAII COPIES DUE DATE(S) SOURCE* NOTES State NAIC CA-L apply to all filinas) I. NAIC FINANCIAL STATEMENTS 1 2003 Annual Statement (8 %" x 14") 2 1 3/1 NAIC 1.1 Printed Investment Schedule (pages E01-E25) 1 1 3/1 NAIC 2 Quarterly Financial Statement (8 %" x 14") for 2 1 5/15, 8/15, NAIC Quarters ending 3/31/04, 6/30/04 and 9/30/04 11/15 II. NAIC SUPPLEMENTS 10 Actuarial Certification 1 1 3/1 Company 11 Investment Risk Interrogatories 1 1 4/1 NAIC 12 Life Supplement 1 1 3/1 NAIC N 13 Long Term Care Exoerience Reporting Forms 1 1 4/1 NAIC 14 Management Discussion & Analysis 1 1 4/1 Company 15 Medicare Supplement Insurance Experience 1 1 3/1 NAIC Exhibit 16 Property/Casualty Supplement 1 1 3/1 NAIC N 17 Risk-Based Capital Report N/A N/A N/A 18 Supplemental Compensation Exhibit 1 N/A 3/1 NAIC 19 SVO Compliance Certification 1 1 3/1, 5/15, NAIC 8/15, 11/15 Ill. NAIC ELECTRONIC FILINGS 30 Annual Statement Electronic Filing N/A 1 3/1 NAIC 0 31 March .PDF Filing N/A 1 3/1 NAIC 0 32 Risk-Based Capital Electronic Filing N/A N/A N/A NAIC 33 Suoolemental Electronic Filing N/A 1 4/1 NAIC 0 34 Supplemental .PDF Filing N/A 1 4/1 NAIC 0 35 June .PDF Filing N/A 1 6/1 NAIC 0 36 Quarterly Electronic Filing N/A 1 5/15, 8/15, NAIC 0 11/15 37 Quarterly .PDF Filing N/A 1 5/15, 8/15, NAIC 0 11/15 • HEAL TH ENTITIES (LICENSED IN HAWAII) • ATTACHMENT HAWAII Memorandum 2003-11 H December 12, 2003 COMPANY NAME: ____________________ NAIC Company Code: --------- Contact: Telephone:-------------- REQUIRED FILINGS IN THE STATE OF HAWAII DURING THE YEAR 2004 (1) (2) (3) (4) (5) (6) (7) Check- Line NUMBER OF FORM APPLICABLE list # REQUIRED FILINGS FOR HAWAII COPIES DUE DATE(S) SOURCE* NOTES State NAIC (A-L apply to all filings) IV. AUDITED FINANCIAL STATEMENTS 51 Accountants Letter of Qualifications 1 N/A 6/1 Company 52 Audited Financial Statements 2 1 6/1 Company 54 Independent CPA-Annual Notification of 1 N/A prior to the Company Accountant/Accounting Firm audit 55 Notification of Adverse Financial Condition 1 N/A 6/1 - If Company applicable 56 Report of Significant Deficiencies in Internal 1 N/A 6/1 - If Company Controls applicable V. STATE FILINGS 101 Filings Checklist (with Column 1 completed) 1 1 Checklist to State accompany NAIC filings 102 Compliance Resolution Fund Assessment 1 0 7/1 State (formerly known as Insurance Regulation Fund Assessment) - Assessment Notice will be sent to insurers 103 Computation of Net Worth (Separate 1 0 3/1 State worksheets for MBS and HMO attached) 104 Grievance Procedures, number of grievances 1 0 3/1 Company handled, causes underlying those grievances, and a summary of disposition of grievances 105 Quarterly Net Solvency Report 1 0 2/14, 5/16, State (for mutual benefit societies under HRS 8/15, 11/14 §432:1-407(g) and HMO under §432D-8(g) 106 Amendments to Charter or Articles of 1 0 Within 60 Company Incorporation, Constitution and Bylaws days after adoption VI. FILINGS FOR HMO INSURERS ONLY 107 List of Providers 1 0 3/1 Company 108 Renewal of Certificate of Authority 1 0 8/16 State *If Form Source is NAIC, the form should be obtained from the appropriate vendor. THE HAWAII INSURANCE DIVISION WILL DESTROY DOCUMENTS, WHICH ARE NOT REQUIRED TO BE FILED (I.E. NOT ON THIS LIST), WITHOUT REVIEW. 2 R R p • • NOTES AND INSTRUCTIONS (A-L APPLY TO ALL FILINGS) [HEAL TH ENTITIES] A Required Filings Contact Person: Compliance Resolution Fund Assessment (Line #102) Gordon Nishiki: (808) 586-0985 E-mail: gnishiki@dcca.hawaii.gov Renewal of Certificate of Authority (Line #110) [HMO Insurers ONLY] Licensing Branch: (808) 586-2788 E-mail: inslic@dcca.hawaii.gov Annual Statement and all other filings: Daniel Cheung: (808) 587-6735 Fax: (808) 587-5379 E-mail: dcheung<@dcca.hawaii.gov B Mailing Address: P. 0. Box 3614 For Postal Delivery Honolulu, HI 96811-3614 ATTN: DANIEL CHEUNG OR For Hand Delivery 335 Merchant Street, 2°d Fir. Honolulu, HI 96813 ATTN: DANIEL CHEUNG c Mailing Address for Filing Fees: Not applicable D Mailing Address for Premium Tax Payments: Not applicable E Delivery Instructions: For filings to be considered as delivered on time, the Insurance Division must receive all filings on or before the indicated due date. If the due date falls on a weekend or a holiday, then the next business day becomes the due date. F Late Filings: Failure or refusal to submit the filings on time are punishable by law including fines, suspension or revocation of the Certificate of Authority. G Original Signatures: The Annual and Quarterly Statement Jurat pages, and the Quarterly Net Solvency Report, shall bear original signatures of at least two of the reporting entity's principal officers. H Signature/Notarization/Certification: Original signatures of the Annual and Quarterly Statement Jurat pages and the Quarterly Net Solvency Report shall be notarized. I Amended Filings: An explanation of the individual amendments shall accompany each amended filing. If there are signature requirements for the original filing, the same should be followed for the amended filing. 3 • • NOTES AND INSTRUCTIONS (A-L APPLY TO ALL FILINGS) [HEAL TH ENTITIES] J Exceptions from normal filings: K Bar Codes (State or NAIC): Not applicable L Affidavit of Filing and Financial Statement Not applicable (foreign insurers are required to submit Attestation: filings in hard copies with the Insurance Division) M NONE Filings: See NAIC Annual Statement Instructions. Exceptions to these instructions are noted on the form N Filings new, discontinued or modified materially New Filings: since last year: 1. Life Supplement (Line #12) 2. Property/Casualty Supplement (Line #16) Discontinued Filing: Fourth quarter quarterly statement Modified Filings: A single copy required for most NAIC supplements and State filings in 2004. 0 Electronic Filing: Electronic filing with the NAIC includes filing via the Internet or filing via diskette. Companies that file with the NAIC via the Internet are not required to submit diskettes to the NAIC. Please review General Instructions for Companies to Use Checklist. p Certificate of Authority: The Insurance Division will notify HMO insurers of the license renewal before August 16 each year. (HMO Insurers ONLY) QUESTIONS - CONT ACT THE LICENSING BRANCH @ (808) 586-2788. E-mail: inslic@dcca.hawaii.gov Q Checks/payments: Checks should be made payable to "DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS, STATE OF HAWAII" unless otherwise noted on the form. A service charge of $15 will be assessed for each dishonored check. Your cancelled check is your receipt; an official receipt will be issued only upon written request. R Accountants Letter of Qualifications Originals of both documents required for filing. Audited Financial Statements Audit shall be prepared in accordance with the NAIC Annual Statement Instructions, following the practices and procedures prescribed by the NAIC Accounting Practices and Procedures Manual. s Websites: Please visit the following websites for additional information: https://www2.naic.org/servlet/lndex http://www.state.hi.us/dcca/ins 4 • 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 send mailing labels and other information to all companies but will not be sending their own checklist this year. Column (1) 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. (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 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 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 complete quarterly filing and the PDF files for all quarterly data. The Quarterly .PDF Filing is the .pdf file 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 (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 have chosen 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. 5 • Column (6) (Form Source) General Instructions For Companies to Use Checklist (Continued) • 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 the state web site). 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. 6