PROPERTY & CASUALTY DMSURERS - osi.state.nm.us · *IfXXX appears in this column, this state does not require this filing, if hard copy is filed with the state of domicile and if the

PROPERTY & CASUALTY DMSURERS

COMPANY NAME:

Contact;

.NAIC Company Code:^

Telephone:

REQUIRED FILINGS IN THE STATE OF: Filings Made During the Year 2018

(1)

Checklist

(2)

Line #

11.1

2

34

11121314151617

18

1920212223

2425262728293031

323334

3536

37

383940414243444546

47

(3)

REQUIRED FILINGS FOR THE ABOVE STATE

I. NAIC FINANCIAL STATEMENTSAnnual Statement (8 i/2" x 14")

Printed Investment Schedule detail (Pages E01-E27)Quarterly Financial Statement (8 Vi" x 14")

Protected Cell Annual StatementCombined Annual Statement (8 Vi" x 14")

II. NAIC SUPPLEMENTSAccident & Health Policy Experience ExhibitActuarial OpinionActuarial Opinion Summary

Bail Bond SupplementCombined Insurance Expense Exhibit

Credit Insurance Experience ExhibitCybersecurity and Identity Theft Insurance Coverage

SupplementDirector and Officer Insurance Coverage Supplement

Financial Guaranty Insurance Exhibit

Insurance Expense Exhibit

Long-Term Care Experience Reporting Forms

Management Discussion & Analysis

Medicare Part D Coverage Supplement

Medicare Supplement Insurance Experience Exhibit

Premiums Attributed to Protected Cells ExhibitReinsurance Summary Supplemental

Reinsurance Attestation Supplement

Exceptions to Reinsurance Attestation Supplement

Risk-Based Capital ReportSchedule SISSupplement A to Schedule T

Supplemental Compensation ExhibitSupplemental Health Care Exhibit (Parts 1,2 and 3)Supplemental Health Care Exhibit's AllocationReport SupplementSupplemental Investment Risk Interrogatories

Supplemental Schedule for Reinsurance CounterpartyReporting Exception - Asbestos and Pollution

Contracts

Trusteed Surplus Statement

III. ELECTRONIC FILING REQUIREMENTSAnnual Statement Electronic FilingMarch .PDF FilingRisk-Based Capital Electronic FilingRisk-Based Capital .PDF FilingCombined Annual Statement Electronic FilingCombined Annual Statement .PDF FilingSupplemental Electronic FilingSupplemental .PDF FilingQuarterly Statement Electronic Filing

Quarterly .PDF Filing

(4)NUMBER OF COPIES*

DomesticState NAIC

ForeignState

(5)

DUE DATE

(6)FORM

SOURCE**

(7)APPLICABLE

NOTES

2EO2

EO1

EOEOEO

EOEO

XXXXXXXXX

XXXXXX

3/13/15/15, 8/15,11/153/15/1

NAICNAICNAIC

NAICNAIC

AAA

AA

EOEOEOEOEOEOEO

EO

EOEOEOEOEO

EOEOEOEOEOEOEOEO

EOEOEO

EOGO

EO

EOEON/AEOEOEOEO

EO

EOEOEOEOEO

EOEOEOEON/AEON/AEO

N/AEOEO

EOEO

EO

XXXXXXXXXXXXXXXXXXXXX

XXX

XXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

N/AXXX

N/AXXXXXX

XXXXXX

XXX

4/13/13/153/15/14/14/1

3/1, 5/15,8/15,11/153/14/14/14/13/1, 5/15,8/15,11/153/13/13/13/13/13/13/13/1, 5/15,8/15,11/153/14/14/1

4/13/1

3/1,5/15,8/15,11/15

NAICCompany

Company

NAICNAICNAICNAIC

NAIC

NAICNAICNAIC

Company

NAIC

NAICNAICNAIC

Company

CompanyNAICNAICNAIC

NAICNAICNAIC

NAICNAIC

NAIC

AAAAAAA

A

AAAAA

AAAAAAAA

AAA

AA

A

NONEEO

NONEEO

NONEEO

NONEEO

NONE

EO

EOEOEOEOEOEOEOEOEO

EO

XXXXXX

N/AN/A

XXXXXXXXXXXXXXX

XXX

3/13/13/13/15/15/14/14/15/15, 8/15,11/155/15, 8/15,11/15

NAICNAICNAICNAICNAICNAICNAICNAICNAIC

NAIC

AAAAAAAAA

A

> 2016 National Association of Insurance Commissioners 1 Property/Casualty

(1)

Checklist

(2)

Line #

48

49505152

5354

5556

57

5859

60

61

626364

6566

6768

69

707172

73

74

75

76

(3)

REQUIRED FILINGS FOR THE ABOVE STATE

Audited Financial Filing June .PDF

TV. AUDIT/INTERNAL CONTROLRELATED REPORTS

Accountants Letter of Qualifications

Audited 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 forindependent CPARelief &om the Requirements for Audit CommitteesRequest to File Consolidated Audited AnnualStatements

Request for Exemption to File Management's Report

of Internal Control Over Financial Reporting

V. STATE REQUIRED FILINGSFilings Checklist (with Column 1 completed)

Signed JuratForm F, Enterprise Risk Report ***

Holding Statements - Form B & C

ORSA ****

Annual Statement Filing Fee

Certificate of ComplianceCertificate of DepositCorporate Governance Annual Disclosure *****

Annual Continuation of Certificate of Authority

Contact Processing Form

Form 12Premium Tax Estimated Quarterly report form 306

Premium & Health Surtitx Tax Final Report form 300

Fraud Assessment

State Health Rate Form Filing Fees

Property and Casualty Filing Fees

(4)NUMBER OF COPIES*

DomesticState

EONAICEO

ForeignState

XXX

(5)

DUE DATE

./I

(6)FORM

SOURCE**

NAIC

(7)APPLICABLE

NOTES

EOEOEOEO

EOEO

EOEO

EO

EOEO

EO

EOEON/A

EON/A

N/AN/A

EO

EOEON/A

N/A

N/AN/AN/AN/A

N/AN/A

N/AN/A

N/A

N/AN/A

N/A

./I1/1

;/1

;/1

•1\

•1\

./I

Company

CompanyCompany

Company

Company

Company

Company

Company

Company

CompanyCompany

Company

1

2***

EO

EO$200

00

**»**

$ Varies

11 ,

1

1

$ Varies

$ Varies

$ Varies

0

000

00

0000

000

0

0

0

0

XXX

XXX***

XXX

XXX$200

11

it****

$Varies

111

1

$ Varies

Varies

$ Varies

With eachdelivery

3/19/154/15

9/13/1

3/13/16/13/1

3/13/1

4/15, 7/15,10/15,1/15

4/15

9/15

As changes

are made

7/1

State

NAICCompany

Company

Company

Statewebsite

StateState

Company

Company

Company

CompanyState

website

Statewebsite

Statewebsite

SERFF

Statewebsite

A

AAA

AA

BB

^^4=^^

B

BBc

c

c

D

E

© 2016 National Association of Insurance Commissioners Property/Casualty

*IfXXX appears in this column, this state does not require this filing, if hard copy is filed with the state of domicile and ifthe data is filed electronically with the NAIC. IfN/A appears in this column, the filing is required with the domiciliarystate. IfEO (electronic only filing).

**IfForm Source is NAIC, the form should be obtained from the appropriate vendor.

***The New Mexico Office of Superintendent of Insurance adopted the Enterprise Risk Report (ERR) in Section 59A-37-30 NMSA 1978. See attached Notes and Instructions for Web link to obtain copy of Form F. For those states that haveadopted the NAIC updated Holding Company Model Act, a Form F ERR 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 bythe company to the NAIC. Note however that this filing is intended to be submitted to the lead state. For moreinformation on lead states, see the following NAIC URL: http://www".naic.org/'publ!c_iead_state_report.htm.

****The New Mexico Office of Superintendent of Insurance requires filing of the Risk Management and Own Risk andSolvency Assessment Model Act (ORSA) Summary Report pursuant to Section 59A-4-3 and 59A-5-29 for companies withwritten premiums in excess of 1 billion dollars. For those states that have adopted the NAIC updated ORSA, a summaryreport is required annually by insurers and insurance groups above a specified premium threshold. Consistent with theForm B filing requirements. The ORSA Summary Report 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 insurancegroup level. For more information on lead states, see the following NAIC URL:http://www.naic.org/public_Ieadstate_report.htm

***** For those states that adopted the NAIC Corporate Governance Annual Disclosure Model Act, an annual disclosureis required of all insurers or insurance groups by June 1. The Corporate Governance Annual Disclosure is a state filingonly 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 if filed at the insurance group level. For more information on lead states, see the following NAIC URL:http://www.naic.org/public_lead_sfate_reporthtm

© 2016 National Association of Insurance Commissioners 3 Property/Casualty

NOTES AND INSTRUCTIONS

A. Examination Bureau InformationRequired Filings:

® Annual Statement, Quarterly Statements & Jurat Page(2 Hard Copy & 1 Electronic Copy)

o This Checklist with each delivery

® Supplemental Filings (Only Electronic Copy)

® Form F, Enterprise Risk Report (Only Electronic Copy)B ORSA (Only Electronic Copy - Premium > $ 1M)a Required Filing Fees and Assessments: - Invoices for each

licensed companies are posted to our web page m pdf format.Please go to:

"2016 Annual Statement Filing Fee Invoices - Due by March 1 2016".Invoices should be available on our web page by February 1,2018.

Contact Person:

We prefer email for inqumes.

Mailing Address:

Delivery Instructions:

Electronic Copy:

Original Signatures Signature/Notarization/Certification:

Amended Filings:

Exceptions from normal filings:

Annual Statement Filing Fees: Use the"Edit/Find" function to search for yourcompany's invoice at the web link usingyou NAIC CoCode. Print the invoiceand mail in with your check.

Examination Bureau

Lucille Valdez505- 827-4390lucille.yaldez(a!state.nm.us

Office of Superintendent of InsuranceExamination Bureau Room 440Lucille Valdez1120PaseodePeraltaSanta Fe,NM 87501or

P.O. Box 1689

Santa Fe,NM 87504-1689

All hard copy filings must bear U.S.postmark or courier service pick-up date

no later than the indicated due date. NewMexico domestic company electronicfiling must be received by the contactperson no later than the indicated duedate. No exceptions.

Electronic (PDF) versions of filings shallbe sent by email. If file is too large sendto FTP site and provide instructions memail for download. Zip files will beblocked by our firewall.

Origmal signatures required on allfilings that require signatures.Follow NAIC instructions.

Amended items must be filed within 10days of their amendment, along with anexplanation of the amendments.

Signature requu-ements for amendments

are the same as for the original filing.


B.

Signed Jurat:

Filing Checklist:

Form F, Section 59A-37-30. Enterprise Risk Report:

Form F is available on the OSI web page at:

!lti]3^/Zwwôsi.state jim/us/Examin£itions/docs/2015/checklists/F(^%2QF%20ENTERPRlSE%20RISK%20REPORT%20FORM.pdf

Company Licensing Bureau Information:Required Filings:

c Annual Continuation of Certificate of Authority Fee

a Certificates of Compliance

® Certificates of Deposita Contact Processing Form

e Form 12

® Instructions are on our website posted in early January.

Above documents must be received in the CompanyLicensing Bureau on or before March 1st. No exceptions.

• Invoices can be found on our website.

Contact Person:

Mailing Address:

The superintendent may grant for goodcause, on or before March 1, a

reasonable extension of time for filingthe annual statement. Send all requests

for filing extensions to the ExammationBureau before the due date of the fileditem.

The Jurat is required for domesticcompanies only and is to be submittedwith the Annual and Quarterly FinancialStatement Filing.

Send Filing Checklist (with Column 1completed) with delivery of each filing.

The person who predominantly controlsan insurer that is subject to registrationshall file an enterprise risk report eachyear. The report shall reflect that person's

knowledge and belief of the material riskswithin the insurance holding companysystem that pose enterprise risk to theinsurer. The report shall be filed with thelead state insurance supervisory officialof the insurance holding company systemand in compliance with the relevantprocedures outlined in the financialanalysis handbook adopted by theNational Association of InsuranceCommissioners (NAIC).

Company Licensing BureauRebecca Lucero

505- 827-4362

Office of Supermtendent of InsuranceCompany Licensing Bureau Room 439

1120 Paseo de PeraltaSanta Fe,NM 87501 orP.O. Box 1689


© 2016 National Association of Insurance Commissioners Property/Casualty

c.


Late Filings:Expiration of Certificate of Authority for failure to timely file.

Original Signatures:

Financial Audit Bureau Information:Required Filings:

a Premium Taxes: Forms are on our website at:

http://www.osi.statejimAis/FinancîalAu^^

® Fraud Assessment: Invoices are due on September 15th and

are available on the following web page:littp:/7wwvv.osi.state.nm.us,''FinancialAydJt/index.aspx

B Property and Casualty Rate and Form Filing Fee:Invoices are due on July 1st and are available on the following

web page:http://www.osi.state.nni.us/PropertyCasuaIty/index.aspx

Contact Person:

Mailing Address for Required Filing Fees, Assessments andPremium Tax Payments:

ALL FEE, ASSESSMENT, INVOICES, FORMS ANDINSTRUCTIONS ARE ACESSED BY COMPANIES ON OSIWEBSITE AND ARE NOT MAILED OUT TO COMPANIES.See:

http://wvvw.osi.state.nm.us/FinancialAudit/index.aspx and

http://www.osi,statejiiii.us/Kx:aininati^^^^^^ and

http: //www. os i, st ate . n in. u s/PropertyCasyaJlv/md^

All filings must bear U.S. postmark orcourier service pick-up date no later than

the indicated due date. No exceptions.

Reinstatement of Certificate ofAuthority Fee is $150.00 and is duewithin 90 days of date of expiration onJune 1st.

Original signatures required on allfilings that require signatures.Follow NAIC instructions.

Financial Audit Bureau Chief,Shawna Maestas

505-827-5781Shawna.Maestas(%state.nm.us

Office of Superintendent of InsuranceFinancial Audit Bureau-Room 433505-827-57811120 Paseo de PeraltaSanta Fe,NM 87501 orP.O. Box 1689


> 2016 National Association of Insurance Commissioners Property/Casualty

D.


Original Signatures:

Signature/Notarization/Certification:Amended Filings:

Amended Premium Tax Forms (Filings new, discontinued ormodified materially since last year):

Exceptions From Normal Filings:

Fraud Assessments are due for all companies on September 15,

2018.

Late Filings and underpayments for taxes and certain fees andassessments: (All premium tax estimated reports, final reports and

payments; Annual Statement Filing Fees; Property and casualtyFiling Fees and Fraud Assessments)

All filings must bear U.S. postmark or

courier service pick-up date no later than

the indicated due date. No exceptions.

Original signatures by the officersindicated on the premium tax forms anddates required on all filings that requiresignatures and dates as indicated on theform or the company will be subject to a$1,000.00 penalty in accordance withstatute.

All premium tax forms and the Juratpage must be notarized or the companywill be subject to a $1,000.00 penalty inaccordance with statute.

All amended premium tax forms must benotarized and must have originalsignatures of Officers listed on formsCompanies may be subject to penaltyspecified below if amendment results inan underpayment from what wasoriginally reported and paid.

No extension may be granted forpayment of premium tax.

Fraud Assessments were due on

December 31st last year, and must be

post marked by September 15, 2018 inorder to avoid a late filing penalty.

All filings in this categoiy that are notpostmarked by their respective duedates, or premiums taxes that are

underpaid, or premium tax forms that are

incomplete will be penalized $1,000 permonth for each month or part thereof thefiling is late, underpaid or incomplete.Supporting Schedules must be submittedwith final premium tax returns to beconsidered complete as per NMPremium Tax instructions, Bulletms

issued by the Supermtendent and allapplicable statutes.


E.

Life & Health Form Filing Bureau:

Contact Person:

Fees are charged when submitting Life & Health Rates & Forms inSERFF.

http:/,''wwvv.osi.state.nm.us/life-health-illing/index.htm

Chief Actuary, Property and Casualty:

Contact Person:

® Required Filing Fees and Assessments: - Property andCasualty Annual Rate and Form Filing Fee invoices will beposted on the OSI website in June 2018 and are due July2018.

Life & Health Form Filing BureauChief, Margaret Pena505-827-4561Margaret.pena(a>,state.nm.us

Filiug Fees. NMSA 59A-6-1Fee ScheduleFiling of forms or rates(1) rates ...$50.00 each

(2) major form-each new form and eachpackage submission, WHICH CANINCLUDE multiple policy forms,application forms, rider forms,endorsements, or amendment

forms... $30.00

(3) incidental forms and rates forms filedfor INFORMATIONAL purposes;riders, applications, endorsements, and

amendments filed individually; ratesservices organizations filings; rates filedfor informational purposes...$15.00

For SERFF filing see:http://www.osi.state.nm.us/life-health-

filing/index.htm

Alan Seeley, Chief Actuary505-827-4307

Alan.seeley(5),state.nm.us

Property and Casualty Filing Fees:Use the "EdiVFind" function to searchfor your company's invoice at the web

link using you NAIC Co Code. Print theinvoice and mail in with your check.


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 NAICwill not be sending their own checklist this year.

Electronic filing is intendeclto be fllmg^s) submitted to the NAIC via the NAIC Internet FiUngîtewhich eliminates the needjora compair^to submitdiskettes or CD-ROM to the NAIC^Companies arenot required to file hard copy filings with 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 placean "x" in this column when mailing 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 Filings

Name of item or form to be filed.

The Amwal Statement Electronic Filing includes the annual statement data and all supplements due March 1, per the AnnualStatement Instructions. This includes all detail investment schedules and other supplements for which the Annual StatementInstructions exempt printed detail.

The March .PDF Filing is the .pdf file for annual statement data, detail for investment schedules and supplements due March1.

The Rish-Based Capital Electronic Filing includes all risk-based capital data.

The Risk-Based CapHal.PDF Filing is the .pdf file for risk-based capital data.

The Supplemental Electronic Filing mcludes 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 Animal Stateinenl.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 Copies

Indicates 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 mvestment 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" columnfor the appropriate schedules and exhibits. Some states have chosen to waive printed quarterly and annual statements fromtheir foreign insurers and to rely upon the NAIC database for these filings. This waiver could include supplemental annualstatement filings. The XXX in this column might signify that the state has waived the paper filing of the annual statementand all supplements.


Column (5) Due Date

Indicates the date on which the company must file the form.

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 filingmstmctions. 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 companyshould carefully read these notes before submitting a filing.

w:\qa\blanks\checklists\2016 filings made in 2017\4 propcklist_2016_filingsmade2017.docx


Documents

PROPERTY & CASUALTY DMSURERS - osi.state.nm.us · *IfXXX appears in this column, this state does not require this filing, if hard copy is filed with the state of domicile and if the