REQUIRED FILINGS IN VIRGINIA Filings Made During the Year 2004
NOTICE: THE FOLLOWING REPRESENTS, IN GENERAL, THE ANNUAL RENEWAL AND RELATED FILINGS
REQUIRED IN VIRGINIA. EACH LICENSED COMPANY IS SENT SPECIFIC FILING INSTRUCTIONS BY LETTER IN
DECEMBER. COMPANIES FILING THE HEALTH BLANK MAY HAVE ADDITIONAL VIRGINIA SUPPLEMENTAL
FILING REQUIREMENTS AS DETAILED ON THE FB, LH OR PC CHECKLISTS.
(1) (2) (3) (4) (5) (6) (7)
Check- Line NUMBER OF COPIES FORM APPLICABLE
list # REQUIRED FILINGS FOR THE ABOVE STATE Domestic Foreign DUE DATE SOURCE NOTES
State NAIC State
I. NAIC FINANCIAL STATEMENTS
1 Annual Statement (8 ½”x14”) 1 1 1 3/1 NAIC A,B,E,F,G,H,I,J,K,M
1.1 Printed Investment Schedule detail (Pages E01 - E 25) 1 1 1 3/1 NAIC A,B,E,F,J,K,M,O
2 Quarterly Financial Statement (8 ½” x 14”) 1 1 1 5/15, 8/15, 11/15 NAIC A,B,E,F,G,H,I,J,K
II. NAIC SUPPLEMENTS
10 Actuarial Certification 1 1 1 3/1 Company A,B,E,F,G,I,J,K,O
11 Investment Risks Interrogatories 1 1 1 4/1 NAIC A,B,E,F,J,K,M
12 Life Supplement 1 1 1 3/1 NAIC A,B,E,F,J,K,M
13 Long-Term Care Experience Reporting Forms 1 1 N/A 4/1 NAIC A,B,E,F,J,K,M,N
14 Management Discussion & Analysis 1 1 1 4/1 Company A,B,E,F,J,K,O
15 Medicare Supplement Insurance Experience Exhibit 1 1 N/A 3/1 NAIC A,B,E,F,J,K,M,N
16 Property/Casualty Supplement 1 1 1 3/1 NAIC A,B,E,F,J,K,M
17 Risk-Based Capital Report 1 1 See Note Y 3/1 NAIC A,B,E,F,G,J,K,Y
18 Supplemental Compensation Exhibit 1 N/A N/A 3/1 NAIC A,B,E,F,J,K
19 SVO Compliance Certification 1 1 1 3/1, 5/15, 8/15, 11/15 NAIC A,B,E,F,I,J,K,O
III ELECTRONIC FILING
30 Annual Statement Electronic Filing N/A 1 N/A 3/1 NAIC
31 March .PDF Filing N/A 1 N/A 3/1 NAIC
32 Risk-Based Capital Electronic Filing N/A 1 N/A 3/1 NAIC
33 Supplemental Electronic Filing N/A 1 N/A 4/1 NAIC
34 Supplemental .PDF Filing N/A 1 N/A 4/1 NAIC
35 June .PDF Filing N/A 1 N/A 6/1 NAIC
36 Quarterly Electronic Filing N/A 1 N/A 5/15, 8/15, 11/15 NAIC
37 Quarterly .PDF Filing N/A 1 N/A 5/15, 8/15, 11/15 NAIC
IV. AUDITED FINANCIAL STATEMENTS
51 Accountants Letter of Qualifications 1 N/A 1 6/1 or 6/30 Company A,B,E,F,J,O,P
52 Audited Financial Statements 1 1 1 6/1 or 6/30 Company A,B,E,F,J,K,O,P
53 Audited Financial Statements Exemption Affidavit 1 N/A 1 3/1 State A,B,E,F,J,O,P
54 Independent CPA Designation 1 N/A 1 Within 5 business Company A,B,E,F,J,O,P
days of change
55 Notification of Adverse Financial Condition 1 N/A 1 Within 5 business Company A,B,E,F,O,P
days of receipt
56 Report of Significant Deficiencies in Internal Controls 1 N/A 1 6/1 or 6/30 Company A,B,E,F,O,P
57 Request for Exemption to File 1 N/A 1 3/1 Company A,B,E,J,O,P
V. STATE REQUIRED FILINGS
101 Filings Checklist (with Column 1 completed) N/A 1 N/A 3/1 State
XXXX 102 State Filing Fees N/A N/A N/A
XXXX 103 Affidavit of Filing N/A N/A N/A L
104 Analysis of Excess Capital & Surplus Investments Report 1 N/A N/A 3/1, 5/15, 8/15, 11/15 State A,B,E,F,J,Q
105 Application for Renewal of License 1 N/A 1 3/1 State A,B,E,F,J
106 Certificate of Advertising Compliance 1 N/A 1 3/1 State A,B,E,F,J,R
107 Certificate of Compliance N/A N/A 1 3/1 Dom. State A,B,E,F,J,S
108 Costs of HMO’s Indemnification and Nonparticipating 1 N/A 1 3/1, 5/15, 8/15, 11/15 State A,B,E,F,J,X
Referral Provider Arrangements
109 Insurance Holding Company System Annual Reg. Stmt. 1 N/A 1 4/30 Company A,B,E,F,J,T
110 Managed Care Health Insurance Plan (“MCHIP”) filings 1 N/A 1 3/1 State/ A,B,E,F,J,O,U
111 Open Enrollment Statement 1 N/A 1 6/1 Company A,B,E,F,J,V
112 Premium Tax/Assessments Filings: 1 N/A 1 3/1 State See Note D
SEPARATE FILING—DIFFERENT ADDRESS
113 Rates of Compensation 1 N/A 1 3/1 Company A,B,E,F,W
114 Report of Assets Pledged, Hypothecated or Encumbered 1 N/A N/A 3/1 State A,B,E,F,J
[Form R10] [Form R11]
115 Request for Information Regarding RIs 1 N/A N/A 3/1 State A,B,E,F,J
116 Statement of Material Changes 1 N/A 1 3/1 State A,B,E,F,J,X
117 Supplementary Stmt. of Covered and Uncovered Expenses 1 N/A 1 3/1, 5/15, 8/15, 11/15 State A,B,E,F,J,X
118 Virginia Business Page 1 1 1 3/1 NAIC A,B,E,F,Z
VA Health 2003 (due 2004) checklist (11/13/03) Page 1
NOTES AND INSTRUCTIONS (A-K APPLY TO ALL FILINGS)
A Required Filings Contact Person: Karen Traylor: 804-371-9908;
B Annual Statement and Related Filings Mailing Address: Annual Statement and Related Filings
State Corporation Commission Courier Delivery:
Bureau of Insurance State Corporation Commission
Financial Regulation Division Bureau of Insurance, Financial
P.O. Box 1157 Regulation Division
Richmond, VA 23218 1st Floor Mailroom
1300 East Main Street
Richmond, VA 23219
C Mailing Address for Filing Fees: N/A
D Information for Premium Tax/Assessments Filings: Contact Administrative Tax Division,
www.state.va.us/scc/division/boi/webpages/boiinstaxinsurancecoinfo.htm 804-371-9096, with any questions.
The tax packet is a SEPARATE filing and SHOULD NOT be
submitted with the Annual Statement and its related filings. Premium Tax Packet Courier Delivery:
First Union National Bank
Premium Tax/Assessment Filings Mailing Address: Lockbox Department
Bureau of Insurance Tax Unit 4340 Innslake Drive
c/o First Union National Bank Glen Allen, VA 23060
P.O. Box 85170
Richmond, VA 23285-5170
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 postmark deadline is extended to the
next business day.
F Late Filings: Late filings are subject to penalties
pursuant to § 38.2-218 of the Code of
G Original Signatures: A printer’s reproduction of “live”
signatures is acceptable.
H Signature/Notarization/Certification: Statements must be signed by at least
two principal officers of the company.
I Amended Filings: Any signature requirements for the
original filing must be followed for
J Exceptions from normal filings: Exemptions or extensions are not
automatically granted to any company.
Requests must be made prior to the filing
K Bar Codes (State or NAIC): NAIC Annual Statement Instructions
should be followed.
L Affidavit of Filing and Financial Statement Attestation: N/A
M NONE Filings: NAIC Annual Statement Instructions for
Supplemental Interrogatories should be
N Filings new, discontinued or modified materially since last year:
Virginia specific forms may be found on the Bureau’s website at http://
Beginning with filings due in 2004, foreign insurers will no longer
need to file these forms in Virginia:
Long-Term Care Experience Reporting Forms
Medicare Supplement Insurance Experience Exhibit
O Foreign Company Filing Requirements: All items filed should include the
Company’s NAIC Group Number along
with the Company Code.
The Bureau of Insurance does not follow
VA Health 2003 (due 2004) checklist (11/13/03) Page 2
the NAIC Annual Statement Instructions
related to investment schedule detail and
certain supplements. Certain items that
are captured on the NAIC database are
required to be submitted in hard copy
format from foreign insurers even if this
information is filed with the domiciliary
state and the NAIC.
P Audited Financial Statements: File in accordance with 14 VAC 5-270
of the Virginia Administrative Code.
Q Analysis of Excess Capital and Surplus Investments Report: Required of Virginia domestics and
foreign and alien companies whose
domiciliary jurisdictions do not regulate
investments in accordance with §
38.2-1400 of the Code of Virginia.
R Certificate of Advertising Compliance: This form must be completed and filed in
accordance with 14 VAC 5-90-170 B by
any insurer authorized to write accident
and sickness insurance in Virginia. The
completion of items 1 and 2 of the form
is not required in Virginia.
This form is not required of companies
licensed pursuant to Chapters 42, 44 or
45 of the Code of Virginia.
S Certificate of Compliance: Must be an original with seal and have
been issued within 3 months of the date
T Holding Company/Form B Filings: File in accordance with 14 VAC
5-260-60 of the Virginia Administrative
Code and § 38.2-1329 of the Code of
U Managed Care Health Insurance Plan (“MCHIP”) Filings: Companies operating managed care
health insurance plans have additional
filing requirements pursuant to Chapter
58 of Title 38.2 of the Code of Virginia.
V Open Enrollment Statement: File in accordance with § 38.2-4217 of
the Code of Virginia.
W Rates of Compensation: Along with their Annual Statement,
companies licensed pursuant to Chapter
45 of the Code of Virginia must file rates
of compensation OR make a statement to
the effect that no changes in such rates
have been made since the last filing in
accordance with § 38.2-4511 of the Code
X Costs of HMO’s Indemnification and Nonparticipating Referral Required only of companies licensed
Provider Arrangements; under Chapter 43 of the Code of
Statement of Material Changes; Virginia.
Supplementary Statement of Covered and Uncovered Expenses:
Y Risk-Based Capital Report: File in accordance with § 38.2-5502 and
§ 38.2-5510 of the Code of Virginia.
Z Virginia Business Page: Page 35—EXHIBIT OF PREMIUMS,
ENROLLMENT AND UTILIZATION
that shows Virginia business should be
included with the Annual Statement even
if the Company has no Virginia business.
VA Health 2003 (due 2004) checklist (11/13/03) Page 3
For Companies to Use Checklist
Please Note: This checklist represents, IN GENERAL, the annual renewal and related filings required in Virginia. Each
licensed company was sent specific filing instructions by letter in December. The NAIC will send mailing labels and other
information to all companies but will not be sending their own checklist.
Electronic filing is intended to include filing via the Internet or via diskette with the NAIC. Companies that file with the NAIC
via the Internet are not required to submit diskettes to the NAIC.
Column (1) (Checklist)
Companies 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 mailing information to the state. Virginia does not request the checklist.
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 printed detail is exempted per
the Annual Statement Instructions. (Virginia does not 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 statement 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. If N/A appears in this
column, the filing is not required.
Column (5) (Due Date)
Indicates the date on which the company must file the form.
Column (6) (Form Source)
If this column contains “NAIC,” the company must obtain the forms from the appropriate vendor. If this column contains “State,”
Virginia will provide the forms with the filing instructions. If this column contains “Dom. State,” the form should be obtained from
the state of domicile. 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.
VA Health 2003 (due 2004) checklist (11/13/03) Page 4
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.
VA Health 2003 (due 2004) checklist (11/13/03) Page 5