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
(1) (2) (3) (4) (5) (6) (7)
Check- Line REQUIRED FILING FOR THE ABOVE STATE NUMBER OF COPIES DUE DATE FORM APPLICABLE
List # Domestic Foreign SOURCE NOTES
State NAIC State
I. NAIC FINANCIAL STATEMENTS
1 Annual Statement (8 ½” x 14”) 1 1 1 3/1 NAIC A,B,E,F,G,H,I,J,K,M
1.1 Printed Investment Schedule detail (Pages E01 – E26) 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,P
II. NAIC SUPPLEMENTS
11 Investment Risks Interrogatories 1 1 1 4/1 NAIC A,B,E,F,J,K,M
12 Management Discussion & Analysis 1 1 1 4/1 Company A,B,E,F,J,K,O,Q
13 Schedule SIS 1 N/A N/A 3/1 NAIC A,B,E,F,J,K,M
14 Statement of Actuarial Opinion 1 1 1 3/1 Company A,B,E,F,G,I,J,K,O
15 Supplemental Compensation Exhibit 1 N/A N/A 3/1 NAIC A,B,E,F,J,K
16 Supplemental Schedule of Business Written By Agency 1 1 N/A 4/1 NAIC A,B,E,F,J,K
17 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 REQUIREMENTS
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
34 Supplemental Electronic Filing N/A 1 N/A 4/1 NAIC
35 Supplemental .PDF Filing N/A 1 N/A 4/1 NAIC
37 Quarterly Electronic Filing N/A 1 N/A 5/15, 8/15, 11/15 NAIC
38 Quarterly .PDF Filing N/A 1 N/A 5/15, 8/15, 11/15 NAIC
33 June .PDF Filing N/A 1 N/A 6/1 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,R
52 Audited Financial Statements 1 1 1 6/1 or 6/30 Company A,B,E,F,J,K,O,Q,R
53 Audited Financial Statements Exemption Affidavit 1 N/A 1 3/1 Company A,B,E,F,J,O,R
54 Independent CPA Designation 1 N/A 1 Within 5 business Company A,B,E,F,J,O,R
days of change
55 Notification of Adverse Financial Condition 1 N/A 1 Within 5 business Company A,B,E,F,O,R
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,R
57 Request for Exemption to File 1 N/A 1 3/1 Company A,B,E,J,O,R
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 and Surplus Investments Report 1 N/A N/A 3/1, 5/15, 8/15, 11/15 State A,B,E,F,J,U
105 Application for Renewal of License 1 N/A 1 3/1 State A,B,E,F,J
106 Certificate of Compliance N/A N/A 1 3/1 Dom. A,B,E,J,O,S
107 Certificate of Deposit N/A N/A 1 3/1 Dom. A,B,E,J,O,T
108 Insurance Holding Company System Annual Reg. Stmt. 1 N/A N/A 4/30 Company A,B,E,F,J,V
109 Premium Tax/Assessment Filings: 1 N/A 1 3/1 State See Note D
SEPARATE FILING—DIFFERENT ADDRESS
110 Producer-Controlled Insurer Report 1 N/A 1 3/1 State A,B,E,F,J,N
111 Report of Assets Pledged, Hypothecated or Encumbered 1 N/A N/A 3/1 State A,B,E,F,J
[Form R10] [Form R11]
112 Request for Information Regarding RIs 1 N/A N/A 3/1 State A,B,E,F,J
VA Title 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/Assessment Filings Mailing Address: Premium Tax Packet Courier Delivery:
Bureau of Insurance Tax Unit First Union National Bank
c/o First Union National Bank Lockbox Department
P.O. Box 85170 4340 Innslake Drive
Richmond, VA 23285-5170 Glen Allen, VA 23060
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: The Producer-Controlled Insurer
Virginia specific forms may be found on the Bureau’s website at http:// Report is required for Virginia domestic
www.state.va.us/scc/division/boi/webpages/boinaicchecklist.htm companies and foreign companies
domiciled in non-accredited states as of
12/31/03 in accordance with
Administrative Letter 2003-8.
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
the NAIC Annual Statement Instructions
VA Title 2003 (due 2004) checklist (11/13/03) Page 2
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 domiliciary
state and the NAIC.
P Quarterly Financial Statements: Required of any company that has been
previously notified by the Bureau of
Insurance to file quarterly statements in
Q Consolidated Basis Filings: If filings are prepared on a consolidated
MD&A-may be submitted on a consolidated basis in accordance with basis, a separate copy must be filed for
NAIC Annual Statement Instructions. each insurer licensed in Virginia.
R Audited Financial Statements: File in accordance with 14 VAC 5-270
of the Virginia Administrative Code.
S Certificate of Compliance: Must be an original with seal and have
been issued within 3 months of the date
T Certificate of Deposit: Required for all insurers not having a
deposit with the Treasurer of Virginia.
U 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.
V 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
VA Title 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 is 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 this year.
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.
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 the annual statement data, detail for investment schedules and all supplements due March
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 supplements 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.
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 Title 2003 (due 2004) checklist (11/13/03) Page 4