NAIC BLANKS (E) WORKING GROUP
Blanks Agenda Item Submission Form
DATE:
05/12/2011
CONTACT PERSON:
TELEPHONE:
FOR NAIC USE ONLY
Agenda Item # 2011-36BWG MOD
Year
2012
Changes to Existing Reporting
[X ]
New Reporting Requirement
[ ]
EMAIL ADDRESS:
REVIEWED FOR ACCOUNTING
PRACTICES AND PROCEDURES IMPACT
ON BEHALF OF:
No Impact [ ]
Modifies Required Disclosure [ X ]
DISPOSITION
NAME:
Joseph Torti III
TITLE:
Superintendent
AFFILIATION:
Rhode Island Insurance Division
ADDRESS:
1511 Pontiac Ave, Bldg. 69-2
Cranston, RI 02920-4407
[
]
[
]
[
]
[
]
[
]
[ X ]
[
]
Rejected For Public Comment
Referred To Another NAIC Group
Received For Public Comment
Adopted Date
Rejected Date
Deferred Date 11/03/2011
Other (Specify)
BLANK(S) TO WHICH PROPOSAL APPLIES
[X ]
[X ]
ANNUAL STATEMENT
INSTRUCTIONS
[
[
]
]
[ X ] Life and Accident & Health
[
] Separate Accounts
[
] Other Specify
[
]
[X ]
QUARTERLY STATEMENT
CROSSCHECKS
Property/Casualty
Fraternal
[X ]
[X ]
[
]
BLANK
Health
Title
Anticipated Effective Date: Annual 2012
IDENTIFICATION OF ITEM(S) TO CHANGE
Delete Note 21H, modify instructions for Exhibit 7 to refer to retained assets and add column to Exhibit 7, Exhibit of Number
of Certificates for Supplementary Contracts, Annuities and Accident & Health Insurance and Exhibit of Number of Policies,
Contracts, Certificates, Income Payable and Account Values In Force for Supplementary Contracts, Annuities, Accident &
Health Insurance and Other Policies for retained asset accounts
REASON, JUSTIFICATION FOR AND/OR BENEFIT OF CHANGE**
At the October 20, 2010 meeting of the Financial Condition (E) Committee, the Committee agreed with the suggestion by the
chair, former Commissioner Gross (VA), that in future years, the Retained Asset Disclosure should be removed from the
Notes and incorporated into the Annual Statement schedules consistent with the suggestions by the ACLI in their comments
letter to the Committee. This proposal formalizes this movement for 2012 and beyond.
NAIC STAFF COMMENTS
Comment on Effective Reporting Date: Annual 2012 should not be a problem
Other Comments:
Statutory Accounting Principles Working Group is working on a Form A to address changes needed to the SAP.
___________________________________________________________________________________________________
** This section must be completed on all forms.
Revised 6/13/2009
© 2012 National Association of Insurance Commissioners
1
ANNUAL STATEMENT INSTRUCTIONS – LIFE, FRATERNAL AND HEALTH
NOTES TO FINANCIAL STATEMENTS
Detail Eliminated To Conserve Space
21.
Other Items
Instruction:
Detail Eliminated To Conserve Space
Illustration:
Detail Eliminated To Conserve Space
Detail Eliminated To Conserve Space
© 2012 National Association of Insurance Commissioners
2
ANNUAL STATEMENT INSTRUCTIONS – LIFE AND FRATERNAL
EXHIBIT 7 – DEPOSIT-TYPE CONTRACTS
This exhibit is intended to capture information about the activity, before and after any reinsurance, for deposit-type contracts.
Include supplementary contracts without life contingencies, annuities certain, retained assets, income settlement options,
premium and deposit funds, and other contracts as defined in SSAP No. 52, Deposit-Type Contracts.
Detail Eliminated To Conserve Space
Line 7
–
Net Surrender or Withdrawal Payments
Include:
The net proceeds paid or payable (after deduction for surrender charges) to the
contract holder.
Amount of retained asset accounts transferred to state unclaimed property funds
during the year.
Detail Eliminated To Conserve Space
ANNUAL STATEMENT INSTRUCTIONS –HEALTH (LIFE SUPPLEMENT)
EXHIBIT 7 – DEPOSIT-TYPE CONTRACTS
To be filed on or before March 1.
This exhibit is intended to capture information about the activity, before and after any reinsurance, for deposit-type contracts.
Include supplementary contracts without life contingencies, annuities certain, retained assets, income settlement options,
premium and deposit funds, and other contracts as defined in SSAP No. 52, Deposit-Type Contracts.
Detail Eliminated To Conserve Space
Line 7
–
Net Surrender or Withdrawal Payments
Include:
The net proceeds paid or payable (after deduction for surrender charges) to the
contract holder.
Amount of retained asset accounts transferred to state unclaimed property funds
during the year.
Detail Eliminated To Conserve Space
© 2012 National Association of Insurance Commissioners
3
ANNUAL STATEMENT INSTRUCTIONS – LIFE
EXHIBIT OF NUMBER OF POLICIES, CONTRACTS, CERTIFICATES, INCOME PAYABLE AND ACCOUNT
VALUES IN FORCE FOR SUPPLEMENTARY CONTRACTS, ANNUITIES,
ACCIDENT AND HEALTH AND OTHER POLICIES
Detail Eliminated To Conserve Space
Supplementary Contracts
Line 2
–
Issued During Year
Include:
Line 3
–
number of retained asset accounts issued/added during the year.
Reinsurance Assumed
Provide number of all cases involved whether reinsured on a case-by-case basis, assumption
reinsurance assumed (100%) or a percent of a block is assumed.
Detail Eliminated To Conserve Space
© 2012 National Association of Insurance Commissioners
4
ANNUAL STATEMENT BLANK – LIFE
EXHIBIT OF NUMBER OF POLICIES, CONTRACTS, CERTIFICATES, INCOME PAYABLE AND ACCOUNT VALUES IN
FORCE FOR SUPPLEMENTARY CONTRACTS, ANNUITIES,
ACCIDENT & HEALTH AND OTHER POLICIES
SUPPLEMENTARY CONTRACTS
1.
In force end of prior year ............
2.
Issued during year.......................
3.
Reinsurance assumed ..................
4.
Increased during year (net) .........
5.
Total (Lines 1 to 4) .....................
Deductions during year:
6.
Decreased (net) ...........................
7.
Reinsurance ceded ......................
8.
Totals (Lines 6 and 7) .................
9.
In force end of year .....................
10.
Amount on deposit .....................
11.
Income now payable ...................
12.
Amount of income payable
Ordinary
Group
1
2
3
4
5
6
Involving Life
Not Involving Life
Retained Asset
Involving Life
Not Involving Life
Retained Asset
Contingencies
Contingencies
Accounts
Contingencies
Contingencies
Accounts
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(a)...........................................................
(a) ...........................................................
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(a)...........................................................
(a) ...........................................................
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(a)
(a)
(a)
(a)
(a)
(a)
ANNUITIES
Ordinary
Group
1
2
3
4
Immediate
Deferred
Contracts
Certificates
1.
In force end of prior year ............ ............................................................... ............................................................... ............................................................... ...............................................................
2.
Issued during year....................... ............................................................... ............................................................... ............................................................... ...............................................................
3.
Reinsurance assumed .................. ............................................................... ............................................................... ............................................................... ...............................................................
4.
Increased during year (net) .........
5.
Totals (Lines 1 to 4)....................
Deductions during year:
6.
Decreased (net) ........................... ............................................................... ............................................................... ............................................................... ...............................................................
7.
Reinsurance ceded ......................
8. Totals (Lines 6 and 7) .................
9. In force end of year ..................... ............................................................... ............................................................... ............................................................... ...............................................................
Income now payable:
10.
Amount of income payable ......... (a)
XXX
XXX
(a)
Deferred fully paid:
11.
Account balance .........................
XXX
(a)
XXX
(a)
Deferred not fully paid:
12.
Account balance
XXX
(a)
XXX
(a)
ACCIDENT AND HEALTH INSURANCE
Group
1
2
Certificates
Premiums in Force
1.
In force end of prior year ................................................................................. ..................................
2.
Issued during year............................................................................................ ..................................
3.
Reinsurance assumed ....................................................................................... ..................................
4.
Increased during year (net) ............................................
XXX
5.
Totals (Lines 1 to 4).......................................................
XXX
Deductions during year:
6.
Conversions .....................................................................................................
XXX
7.
Decreased (net) ................................................................................................
XXX
8.
Reinsurance ceded .........................................................
XXX
9.
Totals (Lines 6 to 8).......................................................
XXX
10.
In force end of year
(a)
Credit
3
4
Policies
Premiums in Force
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................................. ..................................
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XXX
XXX
Other
5
6
Policies
Premiums in Force
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XXX
XXX
XXX
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XXX
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XXX
XXX
XXX
XXX
(a)
XXX
XXX
XXX
XXX
(a)
DEPOSIT FUNDS AND DIVIDEND ACCUMULATIONS
1
2
Deposit Funds
Dividend Accumulations
Contracts
Contracts
1.
In force end of prior year ....................................................................................................................................................................................................................................................................................
2.
Issued during year...............................................................................................................................................................................................................................................................................................
3.
Reinsurance assumed ..........................................................................................................................................................................................................................................................................................
4.
Increased during year (net) .......................................................
5.
Totals (Lines 1 to 4)..................................................................
Deductions during year:
6.
Decreased (net) ...................................................................................................................................................................................................................................................................................................
7.
Reinsurance ceded ....................................................................
8.
Totals (Lines 6 and 7) ...............................................................
9.
In force end of year ...................................................................
10.
Amount of account balance
(a)
(a)
(a) See Paragraph 9 of the Annual Audited Financial Reports in the General section of the annual statement instructions.
© 2012 National Association of Insurance Commissioners
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ANNUAL STATEMENT BLANK – FRATERNAL
EXHIBIT OF NUMBER OF CERTIFICATES FOR SUPPLEMENTARY CONTRACTS, ANNUITIES
AND ACCIDENT & HEALTH INSURANCE
1
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
In force end of prior year ..................................
Issued during year ............................................
Reinsurance assumed .......................................
Increased during year (net) ...............................
Totals (Lines 1 to 4) .........................................
Deductions during year:
Decreased during year (net) ..............................
Reinsurance ceded ............................................
Totals (Lines 6 and 7) .......................................
In force end of year (Line 5 minus Line 8) .......
Amount on deposit ...........................................
Income now payable:
Amount of income payable...............................
Deferred: fully paid:
Deferred: fully paid - account balance ..............
Deferred: not fully paid:
Deferred: not fully paid - account balance
2
3
4
5
Supplementary
Supplementary
Contracts
Accident
Contracts
(Not Involving
Retained
and
(Involving Life
Life
Asset
Individual
Health
Contingencies)
Contingencies)
Accounts
Annuities
Insurance
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XXX
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XXX
XXX
© 2012 National Association of Insurance Commissioners
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XXX
XXX
XXX
ANNUAL STATEMENT BLANK – LIFE, FRATERNAL AND HEALTH (LIFE SUPPLEMENT)
EXHIBIT 7 – DEPOSIT-TYPE CONTRACTS
1
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Balance at the beginning of the year before reinsurance ............................................
Deposits received during the year .............................................................................
Investment earnings credited to the account ..............................................................
Other net change in reserves .....................................................................................
Fees and other charges assessed ................................................................................
Surrender charges .....................................................................................................
Net surrender or withdrawal payments ......................................................................
Other net transfers to or (from) Separate Accounts ...................................................
Balance at the end of current year before reinsurance (Lines 1+2+3+4-5-6-7-8) .......
Reinsurance balance at the beginning of the year ......................................................
Net change in reinsurance assumed ...........................................................................
Net change in reinsurance ceded ...............................................................................
Reinsurance balance at the end of the year (Lines 10+11-12) ...................................
Net balance at the end of current year after reinsurance (Lines 9+13)
2
3
4
5
6
7
Guaranteed
Retained
Dividend
Premium and
Interest
Annuities
Supplemental
Asset
Accumulations
Other
Total
Contracts
Certain
Contracts
Accounts
or Refunds
Deposit Funds
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W:\QA\BlanksProposals\2011-36BWG_Modified.doc
© 2012 National Association of Insurance Commissioners
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