memo

HEAL TH ENTITIES COMPANY NAME: ------------------ NAIC Company Code: MEMORANDUM 2004-llH December IO, 2004 Contact: Telephone:----------- REQUIRED FILINGS IN THE STATE OF: HAW All Filings Made During the Year 2005 (1) (2) (3) (4) (5) (6) (7) Check- Line NUMBER OF COPIES* FORM APPLICABLE list # REQUIRED FILINGS FOR THE ABOVE ST A TE Domestic Forei!ffi DUE DATE SOURCE** NOTES State NAIC State J. NAIC FINANCIAL STATEMENTS I Annual Statement (8 W' X 14") 2 I 2 311 NAIC G,H,L 1.1 Printed Investment Schedule detail (Pages EOJ-E25) I I xxx 311 NAIC 2 Quarterly Financial Statement (8 W' x 14") 2 I 2 5115, 8/15, 11115 NAIC G,H,L II. NAIC SUPPLEMENTS 10 Actuarial Opinion I I I 311 Company 11 Investment Risk Interrogatories I I I 411 NAIC 12 Life Supplement I I I 311 NAIC 13 Long-term Care Experience Reporting Forms I I xxx 411 NAIC 14 Management's Discussion & Analysis I I I 411 Company U, See Line 107 15 Medicare Supplement Insurance Experience Exhibit I I xxx 311 NAIC 16 PropertvlCasualtv Supplement I I I 311 ~ 17 Risk-Based Capital Report I I I 311 18 Supplemental Compensation Exhibit l NIA I 311 NAIC R III. ELECTRONIC FILING REQUIREMENTS 30 Annual Statement Electronic Filing xxx I xxx 311 NAIC 0 31 March .PDF Filing xxx I xxx 311 NAIC 0 32 Risk-Based Capital Electronic Filing xxx 0 NIA 311 NAIC 0 33 Supplemental Electronic Filing xxx I xxx 411 NAIC 0 34 Supplemental .PDF Filing xxx I xxx 411 NAIC 0 35 June .PDF Filing xxx I xxx 611 NAIC 0 36 Quarterly Electronic Filing xxx I xxx 5115, 8/15, 11115 NAIC 0 37 Quarterly .PDF Filing xxx I xxx 5115, 8115, I 1115 NAIC 0 IV x 311 NAIC 0 32 Risk-Based Capital Electronic Filing xxx 0 NIA 311 NAIC 0 33 Supplemental Electronic Filing xxx I xxx 411 NAIC 0 34 Supplemental .PDF Filing xxx I xxx 411 NAIC 0 35 June .PDF Filing xxx I xxx 611 NAIC 0 36 Quarterly Electronic Filing xxx I xxx 5115, 8/15, 11115 NAIC 0 37 Quarterly .PDF Filing xxx I xxx 5115, 8115, I 1115 NAIC 0 IV. AUDITED FINANCIAL STATEMENTS 51 Accountants Letter of Qualifications I NIA I 611 Company 52 Audited Financial Statements 2 I 2 611 Comnany T 53 Audited Financial Statements Exemption Affidavit I NIA I Prior to audit Company 54 Independent CPA I NIA I Prior to audit Comnany s 55 Notification of Adverse Financial Condition I NIA I 611 Company 56 Report of Significant Deficiencies in Internal Controls l NIA I 611 ComPanv 57 Request for Exemption to File I NIA I 311 Comnany V. STATE REQUIRED FILINGS 101 Filings Checklist (with column I completed) I I I With filing State 102 Compliance Resolution Fund Assessment I 0 0 711 State 103 Signed Jurat 2 I 2 With financial NAIC L statement filin!! 104 Computation of Net Worth I 0 I 311 State 105 Grievance Procedures, number of grievances handled, I 0 I 311 Company causes underlying those grievances, and disposition of grievances 106 Quarterly Net Solvency Report I 0 I 2114, 5116, 8115, State H 11114 107 Quarterly Management Discussion & Analysis I 0 I 5115, 8115, 11/15 Company N,U 108 Amendment to Charter, Articles of Incorporation, I 0 I Within 60 days Company Constitution and Bylaws of adoption 109 Amendment to Financial Statement Filings 2 0 2 Within I 0 days NAIC I,L,N Amendment to All Other Filings I 0 I of amendment Various VI 5116, 8115, State H 11114 107 Quarterly Management Discussion & Analysis I 0 I 5115, 8115, 11/15 Company N,U 108 Amendment to Charter, Articles of Incorporation, I 0 I Within 60 days Company Constitution and Bylaws of adoption 109 Amendment to Financial Statement Filings 2 0 2 Within I 0 days NAIC I,L,N Amendment to All Other Filings I 0 I of amendment Various VI. FILINGS FOR HMO INSURERS ONLY 110 List of Providers I 0 I 311 Company 111 Renewal of Certificate of Authority I 0 I 8116 State p *If XXX appears m this column, this state does not reqmre this filmg, 1f hard copy 1s filed with the state of domicile and the NAIC 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. NOTES AND INSTRUCTIONS (A-K 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 #111) [HMO Insurers ONLY] Health Branch: (808) 586-2804 E-mail: inshealth@dcca.hawaii.gov Annual Statement and all other filings: Daniel Cheung: (808) 587-6735 Fax: (808) 587-5379 E-mail: dcheung@dcca.hawaii.gov I B Mailing Address: Health Branch, Insurance Division Department of Commerce & Consumer Affairs For Postal Delivery P. 0. Box 3614 Honolulu, HI 96811-3614 Health Branch, Insurance Division For Hand Delivery Department of Commerce & Consumer Affairs 335 Merchant Street, 2"d Floor Honolulu, HI 96813 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 the filing on or before the indicated due date. If the due date falls on a weekend or a State holiday, then the deadline is extended to the next business day HI 96813 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 the filing on or before the indicated due date. If the due date falls on a weekend or a State holiday, then the deadline is extended to the next business day. 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: Original signatures are required on all filings that require signatures, including third party attestations. H Signature/Notarization/Certification: The Annual and Quarterly Statement Jurat pages, and the Quarterly Net Solvency Report, shall each bear notarized signatures of at least two of the reporting entity's principal officers. I Amended Filings: Amended items must be filed within 10 days of their amendment, along with an explanation of the amendments. If there are signature requirements for the original filing, same should be followed for any amendment. J Exceptions from normal filings: 2 NOTES AND INSTRUCTIONS (A-K APPLY TO ALL FILINGS) [HEAL TH ENTITIES] K Bar Codes (State or NAIC}: Not applicable for Hawaii filings L Signed Jurat: A signed Jurat page in compliance with notes G and H must accompany each and every filing of the annual statement, quarterly financial statement, and amendment(s} thereto. M NONE Filings: See NAIC Annual Statement Instructions. N Filings new, discontinued or modified materially New filing: since last year: Quarterly Management Discussion & Analysis to accompany quarterly financial statement filing on 5/15, 8/15, and 11/15. Please see line #107 and note U. Modified filing: Amended filings must be completed within ten days of their amendment. Please see note I ONE Filings: See NAIC Annual Statement Instructions. N Filings new, discontinued or modified materially New filing: since last year: Quarterly Management Discussion & Analysis to accompany quarterly financial statement filing on 5/15, 8/15, and 11/15. Please see line #107 and note U. Modified filing: Amended filings must be completed within ten days of their amendment. Please see note I. Discontinued filing: SVO Compliance Certification (This filing is now addressed in the General Interrogatories - Part 1} 0 Electronic Filing: Electronic filing with the NAIC includes filing via the Internet or filing via diskette. Please review General Instructions for Companies to Use Checklist. p Certificate of Authority: (HMO Insurers ONLY} The Insurance Division will notify HMO insurers of the license renewal before August 16 each year. Q Checks/Payments: Checks should be made payable to "Department of Commerce and Consumer Affairs." A service charge of $15 will be assessed for each dishonored check. R Supplemental Compensation Exhibit If confidentiality is desired, please submit this exhibit under separate cover from other filings with a request for confidentiality. s Notification of Auditor(s} Insurer must notify the Insurance Commissioner of its selection of auditor before the commencement of its audit. The inclusion in the notification of a statement of qualification for each arid every member of the audit team, evidencing the auditors' knowledge and experience in statutory accounting principles and the health insurance industry, will facilitate approval. T Audited Financial Statements Originals must be submitted for filing. Audit must be prepared in accordance with the NAIC Annual Statement Instructions - Health and procedures prescribed by the NAIC Accounting Practices and Procedures Manual. u Management's Discussion & Analysis (MD&A} MD&A must be prepared in accordance with the NAIC Quarterly and Annual Statement Instructions - Health . T Audited Financial Statements Originals must be submitted for filing. Audit must be prepared in accordance with the NAIC Annual Statement Instructions - Health and procedures prescribed by the NAIC Accounting Practices and Procedures Manual. u Management's Discussion & Analysis (MD&A} MD&A must be prepared in accordance with the NAIC Quarterly and Annual Statement Instructions - Health. A quarterly MD&A compares YTD results for the current year with the corresponding period of the preceding year. v Websites for additional information: www.hawaii.gov/dcca/ins and www.naic.org/ financial statement filing/state instructions.htm 3 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 must use the checklist to submit to a state. Companies should copy the checklist and place an "x" in this column when mailing information to the state and NAIC. 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 nts 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. 4 ly 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. 4 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 with the filing instructions (generally on the state web site) or will mail the forms 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. 5