PROPERTY & CASUALTY INSURERS

PROPERTY & CASUALTY INSURERSCOMPANY NAME:NAIC Company Code:Contact:Telephone:REQUIRED FILINGS IN THE STATE OF:(1)(2)(3)ChecklistLine #REQUIRED FILINGS FOR THE ABOVE STATEFilings Made During the Year 2021(4)NUMBER OF COPIES*DomesticForeignStateNAICState(5)DUE DATE(6)FORMSOURCE**11.12I. NAIC FINANCIAL STATEMENTSAnnual Statement (8 ½” x 14”)Printed Investment Schedule detail (Pages E01-E29)Quarterly Financial Statement (8 ½” x 14”)201EOEOEOxxxxxxxxx34Protected Cell Annual StatementCombined Annual Statement (8 ½” x 14”)110EOxxxxxx3/13/15/15, xxxxxxxxx1EOxxx4/1NAIC232425Financial Guaranty Insurance ExhibitInsurance Expense ExhibitLife, Health & Annuity Guaranty Assessment BaseReconciliation ExhibitLife, Health & Annuity Guaranty Assessment BaseReconciliation Exhibit Adjustment FormLong-Term Care Experience Reporting FormsManagement Discussion & AnalysisMedicare Part D Coverage Supplement3/1, 5/15,8/15, Medicare Supplement Insurance Experience ExhibitPremiums Attributed to Protected Cells ExhibitPrivate Flood Insurance SupplementReinsurance Attestation SupplementExceptions to Reinsurance Attestation SupplementReinsurance Summary SupplementalRisk-Based Capital ReportSchedule SISSupplement A to Schedule NAICNAIC40Supplemental Compensation ExhibitSupplemental Health Care Exhibit (Parts 1, 2 and 3)Supplemental Health Care Exhibit’s AllocationReport SupplementSupplemental Investment Risk InterrogatoriesSupplemental Schedule for Reinsurance CounterpartyReporting Exception – Asbestos and PollutionContractsTrusteed Surplus Statement4/14/13/1, 5/15,8/15, 11/153/13/14/13/13/13/13/13/13/1, 5/15,8/15, 11/153/14/14/11EOxxx3/1, 5/15,8/15, 11/15NAIC6162636465III. ELECTRONIC FILING REQUIREMENTSAnnual Statement Electronic FilingMarch .PDF FilingRisk-Based Capital Electronic FilingRisk-Based Capital .PDF FilingCombined Annual Statement Electronic 021223839II. NAIC SUPPLEMENTSAccident & Health Policy Experience ExhibitActuarial OpinionActuarial Opinion SummaryBail Bond SupplementCombined Insurance Expense ExhibitCredit Insurance Experience ExhibitCybersecurity and Identity Theft Insurance CoverageSupplementDirector and Officer Insurance Coverage Supplement(7)APPLICABLENOTESNAICNAICNAICG, HNAICNAICG, HG, HG, NAICNAICNAICNAICNP

(1)(2)(3)ChecklistLine #REQUIRED FILINGS FOR THE ABOVE STATE(4)NUMBER OF COPIES*DomesticForeignStateNAICState(5)DUE DATE66676869Combined Annual Statement .PDF FilingSupplemental Electronic FilingSupplemental .PDF FilingQuarterly Statement Electronic FilingxxxxxxxxxxxxEOEOEOEOxxxxxxxxxxxx70Quarterly .PDF FilingxxxEOxxx71June .PDF 3IV. AUDIT/INTERNAL CONTROLRELATED REPORTSAccountants Letter of QualificationsAudited Financial ReportsAudited Financial Reports Exemption AffidavitCommunication of Internal Control Related MattersNoted in AuditIndependent CPA (change)Management’s Report of Internal Control OverFinancial ReportingNotification of Adverse Financial ConditionRelief from the five-year rotation requirement forlead audit partnerRelief from the one-year cooling off period forindependent CPARelief from the Requirements for Audit CommitteesRequest to File Consolidated Audited AnnualStatementsRequest for Exemption to File Management’s Reportof Internal Control Over Financial Reporting1111EO1V. STATE REQUIRED FILINGS***Advertising CertificateAnnual Report SupplementCarrier Reporting FormConsumer Complaint Contact UpdateCorporate Governance Annual Disclosure***Exam Assessment FeeFilings Checklist (with Column 1 completed)Form B-Holding Company Registration StatementForm F-Enterprise Risk Report ****Health Insurance Annual Data ReportHealth Report Card SurveyLiquor Liability ReportMaine Fraud and Abuse ReportManaging General Agent ReportMandated Benefit Experience Report (Bulletin 292)ORSA *****Premium TaxState Filing FeesSigned JuratState of Maine PageSupplemental Health Insurance Report (Bulletin 286A)Tick Borne Disease ReportWorker’s Compensation Aggregate Benefits PaidReport25/14/14/15/15, 8/15,11/155/15, /13/13/15/15/14/303/13/13/13/14/303/158/103/1, 5/158/15, mpanyStateStateNAICPPPPC, OG, IPPPPPPDC, PLCompanyStatePStateStatePP

*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 filedelectronically with the NAIC. If N/A appears in 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 allinsurers or insurance groups by June 1. The Corporate Governance Annual Disclosure is a state filing only and should not be submitted by thecompany to the NAIC. Note however that this filing is intended to be submitted to the lead state if filed at the insurance group level. For moreinformation 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 companygroups. Consistent with the Form B 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 lead state. 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 isrequired annually by insurers and insurance groups above a specified premium threshold. The ORSA Summary Report is a state filing only andshould not be submitted by the company to the NAIC. Note however that this filing is intended to be submitted to the lead state if filed at theinsurance group level. For more information on lead states, see the following NAIC URL: http://www.naic.org/public lead state report.htm3

ASee separate Notes and Instructions on website for detailsNOTES AND INSTRUCTIONS (A-K APPLY TO ALL FILINGS)Required Filings Contact Person:BMailing Address:CMailing Address for Filing Fees:DMailing Address for Premium Tax Payments:EDelivery Instructions:FLate Filings:GOriginal Amended Filings:JExceptions from normal filings:KBar Codes (State or NAIC):LMSigned Jurat:NONE Filings:NFilings new, discontinued or modified materially since last year:OPContact Information for Exam Fees:Required by the State of MaineSee separate Notes and Instructions on website for details4

General InstructionsFor Companies to Use ChecklistPlease Note:This state’s instructions for companies to file with the NAIC are included in this Checklist. TheNAIC will not be sending their own checklist this year.Electronic filing is intended to be filing(s) submitted to the NAIC via the NAIC Internet Filing Sitewhich eliminates the need for a company to submit diskettes or CD-ROM to the NAIC. Companiesare 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 placean “x” in this column when submitting 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 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 theAnnual Statement Instructions. This includes all detail investment schedules and other supplements for which the AnnualStatement Instructions exempt printed detail.The March .PDF Filing is the .pdf file for annual statement data, detail for investment schedules and supplements dueMarch 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 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 thecombined Insurance Expense Exhibit.The Combined Annual Statement.PDF Filing is the .pdf file for the Combined annual statement data and the combinedInsurance Expense Exhibit.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 Annual Statement Instructions to waive paper filings of certain NAIC supplements andcertain investment schedule detail if such investment schedule data is available to the states via the NAIC database. Thechecklists reflect this action taken by the Blanks (EX) 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 annualstatements from their foreign insurers and to rely upon the NAIC database for these filings. This waiver could include5

supplemental annual statement filings. The XXX in this column might signify that the state has waived the paper filing ofthe 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 companymust obtain the forms from the appropriate vendor. If this column contains “State,” the state will provide the forms with thefiling instructions. If this column contains “Company,” the company, or its representative (e.g., its CPA firm), is expected toprovide 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 companyshould carefully read these notes before submitting a filing.Revised 10/22/20206

Oct 22, 2020 · COMPANY NAME: NAIC Company Code: Contact: Telephone: REQUIRED FILINGS IN THE STATE OF: Filings Made During the Year 2021 (1) Checklist . 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