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DOMESTIC RISK RETENTION GROUPS (CAPTIVES) (LICENSED IN HAWAII) HAWAII Memorandum 2003-9E 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 apoly 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 %" x 14") 2 1 5/15, 8/15, NAIC 11/15 3 Protected Cell Annual Statement 2 0 3/1 NAIC If aoolicable 4 Combined Annual Statement (8 %" x 14") 2 1 5/1 NAIC If applicable II. NAIC SUPPLEMENTS 10 Accident & Health Policy Experience Exhibit 2 1 4/1 NAIC 11 Combined Insurance Expense Exhibit 2 1 5/1 NAIC 12 Credit Insurance Experience Exhibit 2 1 4/1 NAIC 13 Investment Risk Interrogatories 2 1 4/1 NAIC 14 Financial Guaranty Insurance Exhibit 2 1 3/1 NAIC 15 Insurance Expense Exhibit 2 1 4/1 NAIC 16 Lona Term Care Experience Reporting Forms 2 1 4/1 NAIC 17 Management Discussion & Analysis 2 1 4/1 Company 18 Medicare Supplement Insurance Experience 2 1 3/1 NAIC Exhibit 19 Premiums Attributed to Protected Cells Exhibit 2 1 3/1 NAIC If applicable Note N 20 Risk-Based Capital Report 2 1 3/1 NAIC 21 Schedule SIS 2 N/A 3/1 NAIC 22 Statement of Actuarial Opinion 2 1 3/1 Company 23 Supplement A to Schedule T 2 1 3/1, 5/15, NAIC 8/15, 11/15 24 Suoolemental Compensation Exhibit N/A N/A N/A NAIC 25 SVO Compliance Certification 2 1 3/1, 5/15, NAIC 8/15, 11/15 26 Trusteed Surplus Statement 2 1 3/1, 5/15, NAIC 8/15, 11/15 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 Filina N/A 1 3/1 NAIC 33 Combined Annual Statement Electronic Filing N/A 1 5/1 NAIC PLEASE (If applicable) 34 Combined Annual Statement .PDF Filing N/A 1 5/1 NAIC (If applicable) REFER TO 35 Suoolemental Electronic Filing N/A 1 4/1 NAIC 36 Supplemental .PDF Filing N/A 1 4/1 NAIC NOTEO 37 Quarterly Electronic Filing N/A 1 5/15, 8/15, NAIC 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 1 DOMESTIC RISK RETENTION GROUPS (CAPTIVES) (LICENSED IN HAWAII) HAWAII Memorandum 2003-9E 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) IV. AUDITED FINANCIAL STATEMENTS 51 Accountants Letter of Qualifications 2 N/A 6/1 Company 52 Audited Financial Statements 2 1 6/1 Comoanv 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 '· mentofthe address of the person or firm retained to audit. See HRS conduct the annual audit.] §431 :3-302.5. 55 Notification of Adverse Financial Condition 1 N/A If aaalicable Comoanv 56 Report of Significant Deficiencies in Internal 1 N/A If applicable Company Controls 58 Request to File Consolidated Audited Annual 1 N/A Prior to the Company Statements commencement of the audit V. STATE REQUIRED FILINGS 103 Filings Checklist (with Column 1 completed) 1 1 3/1 State 104 Premium Tax (Annual Statement of Premiums 1 0 3/1 State Received for Taxation Purposes) for year 2003 signed on insurer's behalf by some duly authorized person and notarized. Payment on balance due made payable to the Department of Commerce and Consumer Affairs. 105 State Filing Fees xxx 0 xxx State 106 Affidavit of Filina 0 0 N/A State 107 Annual License Renewal Fee 1 0 4/1 State 108 Captive Questionnaire 1 0 3/1 State 109 Cash and Invested Assets Held in Hawaii 1 0 3/1 State (report as of calendar year end, investments reported at market value) 110 Economic Impact Report (report expenses on 1 0 3/1 State accrual basis) 111 Holding Company Registration Statement 2 0 3/15 Company (Form B) and Summary of Its Registration Statement (Form C) *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. 2 NoteQ NoteC Note P NOTES AND INSTRUCTIONS (A-L APPLY TO ALL FILINGS) (DOMESTIC RISK RETENTION GROUPS-CAPTIVES] A Required Filings Contact Person: Annual Statement and all other filings except those listed below: B Mailing Address: Susan Hansen: (808) 586-7381 Fax: (808) 586-3873 E-mail: shansen@dcca.hawaii.gov ******************** Premium Tax Statement (Line #104) Annual License Renewal Fee (Line #107) Captive Questionnaire (Line #108) Cash and Invested Assets Held in Hawaii (Line #109) Economic Impact Report (Line #110) Craig Watanabe (808) 586-0981 E-mail: caotiveins®dcca.hawaii.aov P. 0. Box 3614 Honolulu, HI 96811-3614 ATTN: SUSAN HANSEN NEW STREET ADDRESS ~ 335 Merchant Street, 2"d Floor Honolulu, HI 96813 (Effective November 13, 2003) ATTN: SUSAN HANSEN C Mailing Address for Filing Fees: Note: The Annual Statement may be mailed with the Annual Tax Return or separately. P. 0. Box 3614 Honolulu, HI 96811-3614 ATTN: CAPTIVE INS. BRANCH NEW STREET ADDRESS ~ 335 Merchant Street, 2"d Floor Honolulu, HI 96813 (Effective November 13, 2003) ATTN: CAPTIVE INS. BRANCH (See Note P) D Mailing Address for Premium Tax Payments: Same as Note B - The Tax Return may be mailed with the Annual Statement or separately. Contact Person: Craig Watanabe (808) 586-0981 E-mail: caotivei ns®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. F Late Filings: Fine for late filing of the audited financial statement, statutory Annual Statement, and quarterly statements. Captives are subject to a fine for filing past the due date of not more than $500 per day. Please inform your captive clients that 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. 3 NOTES AND INSTRUCTIONS (A·L APPLY TO ALL FILINGS) [DOMESTIC RISK RETENTION GROUPS-CAPTIVES) H Signature/Notarization/Certification: Tax Statement (Annual Statement of Premiums Received for Taxation Purposes) signed on insurer's behalf by some dulv authorized oerson and notarized. 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 anv amendment. J Exceptions from normal filings: K Bar Codes (State or NAIC): N/A for all Hawaii filings. L Affidavit of Filing and Financial Statement N/A for Hawaii Domestic RRG/Captive Insurers. Attestation: M NONE Filings: See NAIC Annual Statement Instructions. N Filings new, discontinued or modified None of the filings have been discontinued since last materially since last year: year. Modified Filings: Premiums Attributed to Protected Cells Exhibit - If applicable (Line #19) --- Due date chanaed to March 1. 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 Comoanies to Use Checklist. p Annual License Renewal Fee: $500.00 due on April 1, 2004. E-mail: caotiveinstn'ldcca.hawaii.aov 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 onlv upon written request. R Insurance Forms: Reproductions of Insurance Division's forms are allowed on same size and color of paper. s Websites: Please visit the following websites for additional information: www.naic.org/financial_statement_filing/state_instructions.htm www.hawaii.gov/dcca/ins 4 Please Note: Column (1) STATE OF HAWAII Domestic Risk Retention Groups (Captives) • 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 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 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 Fiiing 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. 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). 5