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DOMESTIC LIFE, ACCIDENT AND HEAL TH INSURERS (LICENSED IN HAWAII) HAWAII Memorandum 2003-6E December 10, 2003 COMPANY NAME: ____________________ NAIC Company Code:---------- Contact: Telephone:-------------- REQUIRED FILINGS IN THE STATE OF: HAWAII Filings Made During the Year 2004 (1) (2) (3) (4) (5) (6) (7) Check· Line NUMBER OF FORM APPLICABLE list # REQUIRED FILINGS FOR THE ABOVE STATE COPIES DUE DATE(S) SOURCE* NOTES Domestic State NAIC (A·L aoolv to all filings) I. NAIC FINANCIAL STATEMENTS 1 Annual Statement (8 %" x 14") 2 1 3/1 NAIC 1.1 Printed Investment Schedule detail 2 1 3/1 NAIC (Pages E01-E26) 2 Quarterly Financial Statement (8%"x14") 2 1 5/15, 8/15, NAIC 11/15 3 Separate Accounts Annual Statement 2 1 3/1 NAIC If applicable (8 Yz" x 14") II. NAIC SUPPLEMENTS 10 Accident & Health Policy Experience Exhibit 2 1 4/1 NAIC 11 Credit Insurance Experience Exhibit 2 1 4/1 NAIC 12 Interest Sensitive Life Insurance Products 2 1 4/1 NAIC Report 13 Investment Risk Interrogatories 2 1 4/1 NAIC 14 Life, Health & Annuity Guaranty Assessment 2 1 4/1 NAIC Base Reconciliation Exhibit 15 Life, Health & Annuity Guaranty Assessment 2 1 4/1 NAIC Base Reconciliation Exhibit Adjustment Form 16 Long Term Care Experience Reporting Forms 2 1 4/1 NAIC 17 Management Discussion & Analvsis 2 1 4/1 Company 18 Medicare Supplement Insurance Experience 2 1 3/1 NAIC Exhibit 19 Risk-Based Capital Report 2 1 3/1 NAIC 20 Schedule SIS 2 N/A 3/1 NAIC 21 Statement of Actuarial Opinion 2 1 3/1 Company 22 Statement on non-guaranteed elements - 2 1 3/1 Company Exhibit 5 Int. #3 23 Statement on par/non-par policies - 2 1 3/1 Company Note N Exhibit 5 Int. 1.1 24 Supplemental Compensation Exhibit N/A N/A N/A NAIC 25 Suoolemental Schedule 0 2 1 3/1 NAIC Note N 26 SVO Compliance Certification 2 1 3/1, 5/15, NAIC 8/15, 11/15 27 Trusteed Surplus Statement 2 1 3/1, 5/15, NAIC 8/15, 11/15 28 Workers' Compensation Carve Out 2 1 3/1 NAIC Supplement 1 DOMESTIC LIFE, ACCIDENT AND HEALTH INSURERS (LICENSED IN HAWAII) HAWAII Memorandum 2003-GE December10,2003 COMPANY NAME: ____________________ NAIC Company Code:---------- Contact: Telephone:-.,,,.------------- REQUIRED FILINGS IN THE STATE OF: HAWAII Filings Made During the Year 2004 (1) (2) (3) (4) (5) (6) (7) Check- Line NUMBER OF FORM APPLICABLE list # REQUIRED FILINGS FOR THE ABOVE STATE COPIES DUE DATE(S) SOURCE* NOTES Domestic State NAIC (A-L apply to all filings) Ill. ELECTRONIC FILING REQUIREMENTS 30 Annual Statement Electronic Filing N/A 1 3/1 NAIC 31 March .PDF Filing N/A 1 3/1 NAIC 32 Risk-Based Capital Electronic Filing N/A 1 3/1 NAIC 33 Separate Accounts Electronic Filing N/A 1 3/1 NAIC PLEASE (if applicable) 34 Separate Accounts .PDF Filing (if applicable) N/A 1 3/1 NAIC 35 Suoolemental Electronic Filing N/A 1 4/1 NAIC REFER TO 36 Supplemental .PDF Filing N/A 1 4/1 NAIC 37 Quarterly Electronic Filing N/A 1 5/15, 8/15, NAIC NOTEO 11/15 38 Quarterly .PDF Filing N/A 1 5/15, 8/15, NAIC 11/15 39 June .PDF Filing N/A 1 6/1 NAIC IV. AUDITED FINANCIAL STATEMENTS 51 Accountants Letter of Qualifications 2 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 [Notification to commencethe Commissioner in writing the name and ment of the address of the person or firm retained to audit. conduct the annual audit.] See HRS §431 :3-302.5 55 Notification of Adverse Financial Condition 1 N/A If applicable Company 56 Report of Significant Deficiencies in Internal 1 N/A If applicable Company Controls V. STATE REQUIRED FILINGS 104 Filings Checklist (with Column 1 completed) 1 1 3/1 State 105 Annual Premium Tax Statement (& payment if 1 0 3/1 State Note R aoolicable)- Form 314 106 State Filing Fees xxx xxx xxx State NoteC 107 Affidavit of Filing 0 0 N/A State 108 Compliance Resolution Fund Assessment 1 0 Due 60 State Note A for (formerly known as Insurance Regulation days after CONTACT PERSON Fund Assessment) - Assessment Notice will demand & PHONE NUMBER be sent to insurers 109 Hawaii Investments (Form 322) 1 0 3/1 State 110 Holding Company Registration Statement 2 0 3/15 Company (Form B) and Summary of Its Registration Statement (Form C) 2 DOMESTIC LIFE, ACCIDENT AND HEALTH INSURERS (LICENSED IN HAWAII) HAWAII Memorandum 2003-6E December10,2003 COMPANY NAME:. ____________________ NAIC Company Code:---------- Contact: Telephone:------------- REQUIRED FILINGS IN THE STATE OF: HAWAII Filings Made During the Year 2004 (1) (2) (3) (4) (5) (6) (7) Check- Line NUMBER OF FORM APPLICABLE list # REQUIRED FILINGS FOR THE ABOVE STATE COPIES DUE DATE(S) SOURCE* NOTES Domestic State NAIC (A-L aoolv to all filings) V. STATE REQUIRED FILINGS (continued) 111 Life Insurance Policy Illustrations - Annual 1 0 Company Company NOTE A FOR Certifications by Officer and Illustration Determina- CONTACT Actuary. (To be filed by all insurers ti on PERSON/PHONE authorized to write LIFE insurance in NUMBER Hawaii, as aoolicable.1 ANDNOTET 112 Quarterly Premium Tax Statements (& 1 0 4/30, 7/31, State Notes payment if applicable) - Form 323 10/31, Rands 1/31/2005 113 Renewal of Certificate of Authority 1 0 8/16 State Note A for (NOTE: This is due 8/16--RECEIVED date, not CONTACT PERSON oostmark date) and Note P *If Form Source is NAIC, the form should be obtained from the appropriate vendor. DOCUMENTS SUBMITTED TO THE HAWAII INSURANCE DIVISION WHICH ARE NOT REQUIRED TO BE FILED (NOT ON OUR LIST} WILL BE DESTROYED WITHOUT REVIEW. 3 . NOTES AND INSTRUCTIONS (A·L APPLY TO ALL FILINGS) [DOMESTIC LIFE AND A & H INSURERS] A Required Filings Contact Person: Annual Statement, Premium Tax and all other filings except those listed below: Susan Hansen: (808) 586-7381 Fax: (808) 586-3873 E-mail: shansen@dcca.hawaii.gov Compliance Resolution Fund Assessment (Line #108) Gordon Nishiki: (808) 586-0985 E-mail: gnishiki@dcca.hawaii.gov Life Insurance Policy Illustrations - Annual Certifications (Line #111) Rate & Policy Branch: (808) 586-2809 E-mail: insrpa@dcca.hawaii.gov Renewal of Certificate of Authority (Line #113) Licensing Branch: (808) 586-2788 E-mail: inslic®dcca. hawaii.oov B Mailing Address: P. 0. Box 3614 Honolulu, HI 96811-3614 ATTN: SUSAN HANSEN OR 335 Merchant Street, 2nd Floor NEW STREET ADDRESS ... (Effective November 13, 2003) Honolulu, HI 96813 ATTN: SUSAN HANSEN Note: The Annual Statement may be mailed with the Annual Tax Return or separately. c Mailing Address for Filing Fees: No filing fees or license fees of any kind are required to be paid at this time. (See Note P) D Mailing Address for Premium Tax Same as Note B -The Tax Return may be mailed with the Payments: Annual Statement or separately. Contact Person: Susan Hansen (808) 586-7381 E-mail: shansen®dcca.hawaii.aov 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. (The exception is the Certificate of Authority Renewal- Line #113. This document is physically due in our office by 8/16.) F Late Filings: Late filings are subject to a fine in an amount not less than $100 and not more than $500 for each day of delinquency. Any insurer failing or refusing to pay the required taxes shall be liable for a fine of $500or10% of the tax due, whichever is greater; plus interest at a rate of 12% per annum on the delinquent taxes. The Commissioner may suspend or revoke the Certificate of Authority of any insurer that fails to file any of the documents required herein. 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 aooropriate corporate officers and be properly notarized. H Signature/Notarization/Certification: Annual Premium Tax Statement requires at least one original signature by an officer, director, or other authorized person and must be properly notarized (including notary seal). 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. 4 NOTES AND INSTRUCTIONS (~PPL Y TO ALL FILINGS) [D.ESTIC LIFE AND A & H INSURERS] . J Exceptions from normal filings: K Bar Codes (State or NAIC): N/A for all Hawaii filings. L Affidavit of Filing and Financial N/A for Hawaii Domestic Insurers. Statement Attestation: M NONE Filings: See NAIC Annual Statement Instructions. N Filings new, discontinued or modified New Filings: materially since last year: Statement on par/non-par policies - Exhibit 5 Int. 1.1 (Line #23) Modified Filings: Supplemental Schedule 0 (Line #25) - This schedule was removed from the Annual Statement and added as a supplemental schedule. Discontinued Filings: Long Term Care Insurance Exhibit 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: No action is required at this time to extend your Certificate of Authority. The necessary forms and instructions will be forwarded to you well in advance of the August 16 extension date. QUESTIONS- CONTACT THE LICENSING BRANCH (@ (808) 586-2788. E-mail: inslic®dcca.hawaii.aov Q Certificate of Compliance NIA for Hawaii Domestic Insurers. Certificate of Deposit Certificate of Valuation R 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 reauest. s Quarterly Premium Tax Statements: Please refer to the enclosed Memorandum regarding Premium Tax Information. ALL authorized insurers are required to file four Quarterly Premium Tax Statements (and payments, if applicable) regardless of tax liability. The filing deadlines for the ~ quarterly statements and tax payments are on or before the last day of the calendar month following the quarter. T Life Insurance Policy Illustrations - Applies only to life policies/certificates with illustrations. Annual Certifications (See§ 431:10D-409, HRS) Companies are not required to provide certifications for those policies/certificates which are not illustrated. This requirement is not applicable to Accident and Health or Sickness insurers. QUESTIONS- CONTACT THE RATE & POLICY BRANCH (808) 586-2809 or E-mail: insroa®dcca.hawaii.aov u Websites: Please visit the following websites for additional information: www.naic.org/financial_statement_filing/state_instructions.htm www .hawaii.gov/dcca/ins 5 Please Note: Column (1) STATE OF HAWAII Domestic Life, Accident and Health Insurers - General Instructions For Companies to Use Checklist 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. Electronic filing with the NAIC is intended to include 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. (Checklist) 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 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 Statement Electronic Filing includes the complete quarterly statement data. The Quarterly Statement .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 domestic 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. Also, phone inquiries should be directed to the proper contact person (See NOTE A). 6