COMPANY NAME: NAIC Company Code: Contact: Telephone .
FRATERNAL SOCIETIESCOMPANY NAME:NAIC Company Code:Contact:REQUIRED FILINGS IN THE STATE OF:Montana(1)(2)(3)ChecklistLine #REQUIRED FILINGS FOR THE ABOVE elephone:Filings Made During the Year 2021I. NAIC FINANCIAL STATEMENTSAnnual Statement (8 ½”x14”)Printed Investment Schedule detail (Pages E01-E29)Quarterly Financial Statement (8 ½” x 14”)Separate Accounts Annual Statement (8 ½”x14”)II. NAIC SUPPLEMENTSAccident & Health Policy Experience ExhibitCredit Insurance Experience ExhibitLife, Health & Annuity Guaranty Assessment Base Reconciliation ExhibitLife, Health & Annuity Guaranty Assessment Base Reconciliation ExhibitAdjustment FormLong-term Care Experience Reporting FormsManagement Discussion & AnalysisMedicare Supplement Insurance Experience ExhibitMedicare Part D Coverage SupplementRisk-Based Capital ReportSchedule SISSupplemental Compensation ExhibitSupplemental Health Care Exhibit (Parts 1, 2 and 3)Supplemental Health Care Exhibit’s Allocation ReportSupplemental Investment Risk InterrogatoriesSupplemental Schedule OSupplemental Term and Universal Life Insurance Reinsurance ExhibitTrusteed Surplus StatementVariable Annuities SupplementVM 20 Reserves SupplementWorkers’ Compensation Carve-Out SupplementActuarial Related ItemsActuarial Certification regarding use 2001 Preferred Class TableActuarial Certification Related Annuity Nonforfeiture Ongoing Compliancefor Equity Indexed AnnuitiesActuarial Certification Related to Hedging required by Actuarial GuidelineXLIIIActuarial Certification Related to Reserves required by Actuarial GuidelineXLIIIActuarial Memorandum Related to Universal Life with Secondary GuaranteePolicies required by Actuarial Guideline XXXVIII 8DActuarial OpinionExecutive Summary of the PBR Actuarial Report (if VM early adopted)Actuarial Opinion on Separate Accounts Funding Guaranteed MinimumBenefitActuarial Opinion on Synthetic Guaranteed Investment ContractsActuarial Opinion on X-FactorsActuarial Opinion required by Modified Guaranteed Annuity ModelRegulationFinancial Officer Certification Related to Clearly Defined Hedging Strategyrequired by Actuarial Guideline XLIIILife PBR Exemption (formerly Companywide Exemption)Management Certification that the Valuation Reflects Management’s Intentrequired by Actuarial Guideline XLIIIRAAIS required by Valuation ManualReasonableness & Consistency of Assumptions Certification required byActuarial Guideline XXXVReasonableness of Assumptions Certification required by ActuarialGuideline XXXVReasonableness & Consistency of Assumptions Certification required byActuarial Guideline XXXVI (Updated Average Market Value)Reasonableness & Consistency of Assumptions Certification required byActuarial Guideline XXXVI (Updated Market Value)Reasonableness of Assumptions Certification for Implied Guaranteed RateMethod required by Actuarial Guideline XXXVIRBC Certification required under C-3 Phase IRBC Certification required under C-3 Phase IIStatement on non-guaranteed elements - Exhibit 5 Int. #3Statement on par/non-par policies – Exhibit 5 Int. 1&2III. ELECTRONIC FILING REQUIREMENTS(4)NUMBER OF COPIES*DomesticStateNAIC(5)DUE xxxxx3/13/15/15, 8/15, xxxxxxxxxxxxxxxxx4/14/14/13/13/1, 5/15, 8/15,11/153/13/13/14/14/14/13/14/13/1, 5/15, oner 7/1NAIC 5, 8/15, 11/15Company1EOxxx3/1,5/15, 8/15, 11/15Company1EOxxx3/1,5/15, 8/15, 11/15Company1EOxxx3/1,5/15, 8/15, , 8/15, nyCompany(7)APPLICABLENOTES
(1)(2)(3)ChecklistLine #REQUIRED FILINGS FOR THE ABOVE 01102103104105106107108109110111112113114Annual Statement Electronic FilingMarch .PDF FilingRisk-Based Capital Electronic FilingRisk-Based Capital .PDF FilingSeparate Accounts Electronic FilingSeparate Accounts .PDF FilingSupplemental Electronic FilingSupplemental .PDF FilingQuarterly Statement Electronic FilingQuarterly .PDF FilingJune .PDF FilingIV. AUDIT/INTERNALCONTROL RELATED REPORTSAccountants Letter of QualificationsAudited Financial ReportsAudited Financial Reports Exemption AffidavitCommunication of Internal Control Related Matters Noted in AuditIndependent CPA (change)Management’s Report of Internal Control Over Financial ReportingNotification of Adverse Financial ConditionRelief from the five-year rotation requirement for lead audit partnerRelief from the one-year cooling off period for independent CPARelief from the Requirements for Audit CommitteesRequest for Exemption to File Management’s Report of Internal ControlOver Financial ReportingV. STATE REQUIRED FILINGSCertificate of ComplianceCertificate of ValuationCorporate Governance Annual Disclosure***Annual Statement Montana State PageFilings Checklist (with Column 1 completed)Insurance Department Financial Examination ReportReport of Montana Insured (RIMR-18)Form B-Holding Company Registration StatementForm F-Enterprise Risk Report ****ORSA *****Small Employer Group Report (SEHRP-18)Funeral Insurance Activity Report (FIAR-18)State Filing FeesSigned Jurat(4)NUMBER OF COPIES*DomesticStateNAIC(5)DUE xxxx3/13/13/13/13/13/14/14/15/15, 8/15, 11/155/15, 8/15, mpanyStateStateStateNAICMNOPQT*If XXX appears in this column, this state does not require this filing, if hard copy is filed with the state of domicile and if the data is filed electronically with the NAIC. If N/A appearsin this column, the filing is required with the domiciliary state. EO (electronic only filing).**If Form Source is NAIC, the form should be obtained from the appropriate vendor.***For those states that have adopted the NAIC Corporate Governance Annual Disclosure Model Act, an annual disclosure is required of all insurers or insurance groups by June 1.The Corporate Governance Annual Disclosure is a state filing only and should not be submitted by the company to the NAIC. Note however that this filing is intended to be submittedto the lead state if filed at the insurance group level. For more information on lead states, see the following NAIC URL: http://www.naic.org/public lead state report.htm.****For those states that have adopted the NAIC updated Holding Company Model Act, a Form F filing is required annually by holding company groups. Consistent with the FormB filing requirements, the Form F is a state filing only and should not be submitted by the company to the NAIC. Note however that this filing is intended to be submitted to the leadstate. For more information on lead states, see the following NAIC URL: http://www.naic.org/public lead state report.htm*****For those states that have adopted the NAIC Risk Management and Own Risk and Solvency Assessment Model Act, a summary report is required annually by insurers andinsurance groups above a specified premium threshold. The ORSA Summary Report is a state filing only and should not be submitted by the company to the NAIC. Note howeverthat this filing is intended to be submitted to the lead state if filed at the insurance group level. For more information on lead states, see the following NAIC URL:http://www.naic.org/public lead state report.htm
ABNOTES AND INSTRUCTIONS (A-N APPLY TO ALL FILINGS)Required Filings Contact Person:Montana Commissioner of Securities and Insurance, Examinations Bureau: 406-444-2040 or Fax 406-444-3497E-mail Addresses: CSIExams@mt.govMailing Address:Montana Commissioner of Securities and InsuranceExaminations Bureau840 Helena AvenueHelena, MT 59601CAll forms/documentation may also be submitted electronically to CSIExams@mt.gov. Electronic signatures are acceptable.Mailing Address for Filing Fees:DMailing address is same as B. Fees totaling 35 [Sections 33-7-118(1) and 33-7-217(2), MCA] due March 1. Include copy of annual statement Montanastate page with fees. If due date falls on weekend or holiday, deadline is extended to next business day.Delivery Instructions: Make checks payable to “Commissioner of Insurance, State of Montana.”EAll filings must be postmarked no later than the indicated due date. If due date falls on weekend or holiday, deadline is extended to next business day.Late Filings:FFines may be assessed and the authority to do business in Montana may cease if filings are not made in time provided [Section 33-7-118(3), MCA].Original Signatures:GForeign insurers may use facsimile signatures or reproductions of original signatures on Signed Jurat page.Amended Filings:HSee NAIC Annual Statement Instructions for guidance on amended filingsExceptions from normal filings:IForeign companies must include a copy of any exemption or extension received by its state of domicile to receive such from Montana.Bar Codes (State or NAIC):JMontana is not currently using Bar Codes.Signed Jurat:KMontana waives foreign insurers from filing printed annual statements and NAIC supplements if filed with the state of domicile and the NAIC, and if filedelectronically with the NAIC. The Signed Jurat page is due March 1. Facsimile signatures or reproductions of original signatures may be used. In theevent that any financial data is refiled or amended, a newly completed Jurat page is required.NONE Filings:LSee NAIC Annual Statement Instructions. Exceptions are noted in the instructions.Filings new, discontinued or modified materially since last year:MNone of the filings have been discontinued since last year.Certificate of Compliance:NOEach foreign insurer shall file a Certificate of Compliance issued by the public official having supervision of insurance in the insurer’s state of domicile. Itshall certify that the company is duly organized and authorized to transact insurance therein and the kinds of insurance it is authorized to transact. DueMarch 1.Certificate of Valuation: This state does not require this filing, if hard copy is filed with the state of domicile and if the report can be providedshould our agency request a report.Insurance Financial Examination Report: This state does not require this filing, if hard copy is filed with the state of domicile and if the reportis filed electronically with the NAICP.Report of Insured Montana Residents (RIMR-18):QThis report is required if your company is licensed to transact Disability (Health) insurance in Montana. Due March 1. NO FILING REQUIRED IF NODATA TO REPORT.Small Employer Group Activity Report (SEHRP-18):RThis report is required if your company is licensed to transact Disability (Health) insurance in Montana. Due March 1. NO FILING REQUIRED IF NODATA TO REPORT. .Audited Financial Statements:SPlease refrain from submitting the Audited Financial Statements to this office until further notice.Statement of Actuarial Opinion:TMontana no longer requires the Statement of Actuarial Opinion if hard copy is filed with the state of domicile and NAIC, and if filed electronically with theNAIC.Funeral Insurance Activity Report (FIAR-18): ARM 6.6.1008 provides that the Commissioner may require issuers of funeral insurance to file asupplement to the annual statement. Funeral insurance is a type of life insurance as defined in MCA 33-20-1501 and may be included in a life insurancepolicy or a limited policy or certificate with a guaranteed death benefit.This report is enclosed if your company is licensed to transact Life insurance in Montana. Due March 1. NO FILING REQUIRED IF NO DATA TOREPORT. .
General InstructionsFor Companies to Use ChecklistPlease Note:This state’s instructions for companies to file with the NAIC are included in this Checklist. The NAIC will not be sending their own checklistthis year.Electronic filing is intended to be filing(s) submitted to the NAIC via the NAIC Internet Filing Site which eliminates the need for a companyto submit diskettes or CD-ROM to the NAIC. Companies are not required to file hard copy filings with the NAIC.Column (1)ChecklistCompanies 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 submittinginformation 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 FilingsName 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 alldetail 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 Risk-Based Capital.PDF Filing is the .pdf file for 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 Supplement.PDF Filing is the .pdf file for all supplemental schedules and exhibits due April 1.The Quarterly Electronic Filing includes the quarterly statement data.The Quarterly.PDF Filing is the .pdf for quarterly statement data.The June.PDF Filing is the .pdf file for the Audited Financial Statements and Accountants Letter of Qualifications.Column (4)Number of CopiesIndicates the number of copies that each foreign or domestic company is required to file for each type of form. The Blanks (EX) Task Force modified the 1999 AnnualStatement Instructions to waive paper filings of certain NAIC supplements and certain investment schedule detail, if such investment schedule data is available to thestates via the NAIC database. The checklists reflect this action taken by the Blanks (EX) Task Force. XXX appears in the “Number of Copies” “Foreign” column for theappropriate schedules and exhibits. Some states have chosen to waive printed quarterly and annual statements from their foreign insurers and to rely upon the NAICdatabase for these filings. This waiver could include supplemental annual statement filings. The XXX in this column might signify that the state has waived the paperfiling of the annual statement and all supplements.Column (5)Due DateIndicates the date on which the company must file the form.Column (6)Form SourceThis column contains one of three words: “NAIC,” “State,” or “Company,” If this column contains “NAIC,” the company must obtain the forms from the appropriatevendor. If this column contains “State,” the state will provide the forms with the filing instructions. 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 NotesThis 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 beforesubmitting a filing.
MONTANA COMMISSIONER OF SECURITIES ANDINSURANCE840 HELENA AVENUEHELENA, MONTANA 59601(406) 444-2040Report of InsuredMontana Residentsunder health or disability insurance policies(Report due March 1)Mont. Code Ann. § 33-2-704NO FILING REQUIRED IF NO DATA TO REPORT(Name of Company)(N.A.I.C. #)(Mailing Address - Street or P.O. Box)(City-State-ZIP)Section 33-2-704, MCA, requires each insurer providing health or disability insurance to report the number of Montana residentsinsured under any policy of individual or group health or disability insurance. If your company provides excess of loss or stop losshealth or disability insurance, you must also include in your count of covered individuals all Montana residents whose coverage isreinsured in whole or in part by your company. For the purposes of this report, February 1, 2021 should be used as the date fordetermining the number of Montana residents insured.An excess of loss or stop loss health or disability insurer may exclude from its count of insured individuals those who have beencounted by a primary health or disability insurer or a primary reinsurer. However, the insurer should include in its count the numberof individuals it covers under an excess of loss or stop loss health or disability policy for which the individuals have not been countedby a primary insurer. For example, the insurer should include all individuals in its count if excess of loss or stop loss health ordisability insurance policies are issued to self-insured employers or plans, multiple employer welfare arrangements, or any otherhealth insurance situations in which first dollar coverage is not provided by a primary insurer.IMPORTANT!: If the number of Montana residents insured by health or disability insurance is not known, provide an estimate asdirected on the reverse side of this form.1.Number of Montana residents insured under any individual or group health ordisability insurance policy, including excess of loss or stop loss insurancepolicies covering health or disability insurance in effect as of February 1, 20212.The number of insured lives reported on line 1 above is based on (check one of the following boxes):(a) An actual count of lives insured . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [(b) An estimated count of lives insured, pursuant to the directionson the reverse side of this form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .][ ](actual)(estimate)The foregoing is a full, true and correct statement according to the best of my knowledge, information, and belief.(Signature of Officer)(Printed name and title of officer)(Date)(Telephone number)
INSTRUCTIONS FOR ESTIMATING THE COUNT OF INSURED LIVESThe following are guidelines for estimating the number of insured lives in Montana covered by disability insurance (asdefined in 33-1-207, MCA) by your company.For indemnity and HMO disability insurance plans, estimate this number of insured lives by following these steps. Ademonstration of the calculation shown in steps 5 and 6 below, shown separately for each disability insurance policy formwith premium volume in Montana, must accompany this estimate.1.Determine the total 2020 disability insurance premium on policies in force during the year, separately for eachpolicy form.2.For each policy form, determine the "average plan" sold under that form. Plans may be differentiated bydeductible/coinsurance level or by other features unique to specific plans. The "average plan" is the plan whichmost nearly represents the total plans sold under that policy form. This could be the plan with the highestpremium volume, a plan between (in value) two or more plans with significant premium volumes, or a planselected
COMPANY NAME: NAIC Company Code: Contact: Telephone: REQUIRED FILINGS IN THE STATE OF: Montana Filings Made During the Year 2021 . Montana waives foreign insurers from filing printed annual statements and NAIC supplements if filed with the state of domicile and the NAIC, and if filed electronically with th
COMPANY NAME NAIC COMPANY CODE . CONTACT PHONE . REQUIRED FILINGS IN THE STATE OF: WISCONSIN Filings Made During the Year 2021 (1) Check-list (2) Line # . * If XXX appears in this column, this state does not require this filing if hard copy is filed with the state of domicile and the NAIC
Granite State Health Plan, Inc. (NH) NAIC #14226 39-0993433 Bankers Reserve Life Insurance Company of Wisconsin (WI) NAIC #71013 86-0819817 Hallmark Life Insurance Co. (AZ) NAIC #60078 20-8570212 Magnolia Health Plan, Inc. (MS) NAIC #1392) 39-1678579 Managed Health Services Insurance .
Credit for Reinsurance Model Law (Model #785), NAIC, 2016. 3. Credit for Reinsurance Model Regulation (Model #786), NAIC, 2012. 4. Term and Universal Life Insurance Reserve Financing Model Regulation (Model #787), NAIC, 2017. (Reserve Financing Model Regulation) 5. Life and Health Reinsurance Agreements Model Regulation (Model #791), NAIC, 2002.
Purposes and Procedures Manual of the NAIC Investment Analysis Office NAIC Securities Valuation Office and NAIC Structured Securities Group Effective for Statements ending Decembe
Project Name: Homeowners Rate Revision Status of Filing in Domicile: Not Filed Project Number: HCA0703-105800 Domicile Status Comments: . Company Name Company Name Company Name NAIC Company Code CDI Filing No. ( Department use only ) NAIC Company Code CDI Filing No. (
COMPANY NAME: NAIC Company Code: Contact: Telephone: REQUIRED FILINGS IN THE STATE OF: Filings Made During the Year 2020 (1) . this state does not require this filing, if hard copy is filed with the state of domicile and if the data is filed electronically with the NAIC. If N/A ap
American Contractors Insurance Group Insurance Company NAIC Group #0594 NAIC #19984 MISSOURI EXAMINATION# 1104-14-TGT NAIC EXAM TRACKING SYSTE:W # M0341-M35 January 24, 2013 American Contractors Insurance Group Insurance Company 12222 Merit Drive, Suite 1660 Dallas, Texas 75251
transactions would allow participants to enter in commercial bilateral transactions to find a counterparty that will assume the Capacity Supply Obligation (“CSO”) and mitigate exposure ‒Reliability can be improved by finding a counterparty in the bilateral window for a given season since in times of scarcity, in ARA3 the CSO may not be acquired by another resource . Current Rules 3 T
