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' • • DOMESTIC RISK RETENTION GROUPS (CAPTIVES) (LICENSED IN HAWAII) HAWAII Memorandum 2004-10E December 10, 2004 COMPANY NAME: ____________________ NAIC Company Code:---------- Contact: Telephone:__,..,.---,------------ REQUIRED FILINGS IN THE STATE OF: HAWAII Filings Made During the Year 2005 (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-K apply to all filings) I. NAIC FINANCIAL STATEMENTS 1 Annual Statement (8 %" x 14") 2 1 311 NAIC 1.1 Printed Investment Schedule detail 2 1 311 NAIC (Pages E01-E25) 2 Quarterly Financial Statement (8 %" x 14") 2 1 5115, 8115, NAIC Include the Printed Investment Schedule 11115 detail (Pages E01-E08) 3 Protected Cell Annual Statement 2 0 311 NAIC If applicable 4 Combined Annual Statement (8 %" x 14") 2 1 511 NAIC If applicable II. NAIC SUPPLEMENTS 10 Accident & Health Policy Experience Exhibit 2 1 411 NAIC 11 Combined Insurance Expense Exhibit 2 1 511 NAIC 12 Credit Insurance Experience Exhibit 2 1 411 NAIC 13 Investment Risk lnterroQatories 2 1 411 NAIC 14 Financial Guaranty Insurance Exhibit 2 1 311 NAIC 15 Insurance Expense Exhibit 2 1 411 NAIC 16 Long Term Care Experience Reporting Forms 2 1 411 NAIC 17 Management Discussion & Analysis 2 1 411 Company 18 Medicare Supplement Insurance Experience 2 1 311 NAIC Exhibit 19 Premiums Attributed to Protected Cells Exhibit 2 1 311 NAIC If applicable 20 Risk-Based Capital Report 2 1 311 NAIC 21 Schedule SIS 2 NIA 311 NAIC 22 Statement of Actuarial Opinion 2 1 311 Company 23 Supplement A to Schedule T 2 1 311, 5115, NAIC 8115, 11115 24 Supplemental Compensation Exhibit NIA NIA NIA NAIC 25 Trusteed Surplus Statement 2 1 311, 5115, NAIC 8115, 11115 Ill. ELECTRONIC FILING REQUIREMENTS 30 Annual Statement Electronic Filini:J NIA 1 311 NAIC 31 March .PDF Filing NIA 1 311 NAIC 32 Risk-Based Capital Electronic Filing NIA 1 311 NAIC 33 Combined Annual Statement Electronic Filing NIA 1 511 NAIC PLEASE (If applicable) 34 Combined Annual Statement .PDF Filing NIA 1 511 NAIC (If applicable) REFER TO 35 Supplemental Electronic Filing NIA 1 411 NAIC 36 Supplemental .PDF Filing NIA 1 411 NAIC NOTEO 37 Quarterly Electronic Filing NIA 1 5115, 8/15, NAIC 11115 38 Quarterly .PDF Filing NIA 1 5115, 8115, NAIC 11115 39 June .PDF Filing NIA 1 611 NAIC • • DOMESTIC RISK RETENTION GROUPS (CAPTIVES) (LICENSED IN HAWAII) HAWAII Memorandum 2004-10E December 10, 2004 COMPANY NAME:. ____________________ NAIC Company Code:---------- Contact: Telephone:-..,,,---.,,...-....,..-.,...--------- REQUIRED FILINGS IN THE STATE OF: HAWAII Filings Made During the Year 2005 (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-K apply to all filings) IV. AUDITED FINANCIAL STATEMENTS 51 Accountants Letter of Qualifications 2 NIA 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 ment of the 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 applicable Company 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 0 311 State Received for Taxation Purposes) for year 2004 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 Signed Jurat 0 0 N/A NAIC Domestic - See Note G for Jurat Page Requirements Foreign/Alien - Please do NOT file the Signed Jurat Paae - See Note L Signed Jurat 107 Annual License Renewal Fee 1 0 411 State 108 Captive Questionnaire 1 0 311 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 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 Note C Notes G and L Note P • • NOTES AND INSTRUCTIONS (A-K APPLY TO ALL FILINGS) [DOMESTIC RISK RETENTION GROUPS-CAPTIVES] A Required Filings Contact Person: (Line #104) Premium Tax Statement (Line #107) Annual License Renewal Fee (Line #108) Captive Questionnaire B Mailing Address: C Mailing Address for Filing Fees: (Line #109) Cash and Invested Assets Held in Hawaii (Line #110) Economic Impact Report Craig Watanabe (808) 586-0981 E-mail: captiveins@dcca.hawaii.gov ******************** Annual Statement and all other filings except those listed above: Susan Hansen: (808) 586-7381 Fax: (808) 586-3873 E-mail: shansen@dcca.hawaii.gov P. 0. Box 3614 Honolulu, HI 96811-3614 ATTN: SUSAN HANSEN 335 Merchant Street, 2nd Floor Honolulu, HI 96813 ATTN: SUSAN HANSEN Note: The Annual Statement may be mailed with the Annual Premium Tax Return or separately. P. 0. Box 3614 Honolulu, HI 96811-3614 ATTN: CAPTIVE INS. BRANCH 335 Merchant Street, 2nd Floor Honolulu, HI 96813 ATTN: CAPTIVE INS. BRANCH (See Note P) D Mailing Address for Premium Tax Payments: Same as Note B - The Annual Premium Tax Return may be mailed with the Annual Statement or separately. Contact Person: Craig Watanabe (808) 586-0981 E-mail: caotiveins®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-K APPLY TO ALL FILINGS) [DOMESTIC RISK RETENTION GROUPS-CAPTIVES] H Sig nature/Notarization/Certification: Tax Statement (Annual Statement of Premiums Received for Taxation Purposes) signed on insurer's behalf by some duly authorized person 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 Signed Jurat: The NAIC added this filing (for Foreign Insurers ONLY) to replace last year's "Affidavit of Filing and Financial Statement Attestation." The Affidavit was NOT required for Foreign/Alien Insurers. The Signed Jurat is also NOT required for Foreign/Alien Insurers. Domestic Insurers - see Note G for Jurat Page requirements. M NONE Filings: See NAIC Annual Statement Instructions. N Filings new, discontinued or modified Discontinued Filings: materially since last year: SVO Compliance Certification (This filing is now addressed in the General Interrogatories - Part 1 under the Investment Category - #26.1 and 26.2) 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 Annual License Renewal Fee: $500.00 due on April 1, 2005. E-mail: caotiveins®dcca.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 only 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 Annuar 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. 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