| 2012 Annual Statement Filing Checklist Notes |
Note 1
Supplemental Compensation Exhibit
(Domestic Companies Only)
All Massachusetts domestic insurance companies are required to file this exhibit with the Massachusetts Division of Insurance as part of their Annual Statement filing. Each domestic insurer shall file the most recent version of the exhibit, as provided by the National Association of Insurance Commissioners:
Supplemental Compensation Exhibit 
Instructions specific to “PART 1 – INTERROGATORIES”:
Question 1 – If there is an allocation to each insurer within the group, provide a description of the allocation methodology on the exhibit.
Question 2 – If the answer is “Yes’, provide the commission as part of “All Other Compensation” reported in Column 5 of Part 2, or Column 3 of Part 3 on the exhibit.
Question 3 – If the answer is “Yes”, provide a description of any salary, compensation or emolument that will extend beyond a period of 12 months of the date of the agreement on the exhibit.
Instructions specific to “PART 2 – OFFICERS and EMPLOYEES COMPENSATION”:
The reporting insurer shall provide compensation information for the chief executive officer (or similar title) and the next four most highly compensated other officers of the company. Any former officer or employee whose total compensation meet this criterion shall be included on this exhibit, even if such officer of employee was not an officer or employee of the company at year-end. Any former officers or employees included on the exhibit shall be identified as “Former”.
The reporting insurer shall also provide compensation information for the next five most highly compensated employees of the company whose individual pre-allocation total compensation exceeds $100,000.
Instructions specific to “PART 3 – DIRECTOR COMPENSATION”:
All persons who serve as a Director of the reporting insurer during the reporting year, whether compensated or uncompensated, shall be provided in Part 3, including employees who served as a Director during the reporting year. The Director’s name and principal position or occupation shall be provided on the exhibit.
Note 2
Premium Taxes
Premium tax forms and/or payments are NOT to be filed with the Division of Insurance. All tax matters in Massachusetts, other than surplus lines premium taxes, are under the supervision of the Commissioner of Revenue. For information regarding premium tax forms and/or payments, please contact:
Commissioner of Revenue
Audit Division
Banking & Insurance Unit
PO Box 7052
Boston, MA 02204
Telephone: 617-887-6710
Note 3
State Filing Fees and License Renewal Applications Mailing Address
(Except for HMO's)
All checks for state filing fees with Lock Box Form and License Renewal Application (where applicable) are to be mailed to:
Massachusetts Division of Insurance
Annual Filing Fee / Company License Renewal
PO Box 370039
Boston, MA 02241-0739
HMO License Renewal/Notification of Material Changes Mailing Address
All HMO License Renewal/Notification of Material Changes, with a check for the nonrefundable HMO License Renewal fee of $1,000.00 are to be mailed to:
Commonwealth of Massachusetts
Division of Insurance
Financial Surveillance Section
1000 Washington Street, Suite 810
Boston, MA 02118-6200
Note 4
Claims in Suit
M.G.L. Chapter 175, Section 27, requires that the Company prepare a schedule showing all Massachusetts claims for losses in suit during the year, including suits disposed of during the year and those outstanding at year end. This schedule relates only to policyholders' suits against the Company. Do not include suits against an insured defended by the Company under liability policies. Insert the amount presented in the proof of claim if Ad Damnum and amount claimed differ. For companies writing fidelity and surety lines, the schedule must show all suits against bonds issued by the Company. The schedule shall reflect the following information:
1 Policy/Bond Number
2 Date of Loss
3 Date of Notice of Suit
4 Amount Claimed
5 Amount Paid to Claimant to Date
6 Name of Local Attorney in Charge of Case
7 Reason for Resisting Claim
If there are no suits in process, the schedule must so indicate.
Note 5
Form AR - 1 Certificate of Assuming Insurer
This form is required to be filed by those companies that are Accredited Reinsurers only.
Note 6
Workers' Compensation Schedule C - 1
This form is required to be filed by any foreign Company authorized for Workers' Compensation in Massachusetts that has an AM Best Rating of "B++" or lower.
This form is not required to be filed by any foreign Company authorized for Workers' Compensation in Massachusetts that has an AM Best Rating of "A-" or higher. The required Workers' Compensation deposit for these companies is $50,000.00.
Note 7
Holding Company Registration Statement (Except for HMO's)
Holding Company Registration Statement Affidavit (Except for HMO's)
M.G.L. Chapter 175, Section 206C, requires that every insurer that is authorized to do business in Massachusetts and which is a member of an insurance holding company system to register with the Commissioner. Foreign companies that file a registration statement under the laws of their domiciliary state, with disclosure requirements and standards substantially similar to those prescribed in Section 206C, are exempt from the filing requirement provided the domiciliary state grants a similar exemption for insurers domiciled in Massachusetts.
Foreign companies qualifying for this exemption must complete the Holding Company Registration Statement Affidavit, attesting that a registration statement has been filed with an appropriate state regulatory authority. The affidavit must be signed by an officer of the Company.
Non-exempt foreign companies shall prepare and submit the registration statement required by Section 206C.
If the filing of a holding company registration statement or affidavit does not apply to the Company, it should be so reported along with the reason(s) for non-applicability.
HMO Holding Company Registration Statement
M.G.L. Chapter 176G, Section 28, requires that every health maintenance organization that is authorized to do business in Massachusetts and which is a member of a health maintenance organization holding company system to register with the Commissioner. Foreign health maintenance organizations that file a registration statement under the laws of their domiciliary state, with disclosure requirements and standards substantially similar to those prescribed in Section 28, are exempt from the filing requirement.
If the filing of a holding company registration statement does not apply to the HMO, it should be so reported along with the reason(s) for non-applicability.
Note 8
Massachusetts no longer requires hard copies of annual statements and related filings for all foreign companies licensed or authorized in Massachusetts except Fraternal Benefit Societies and Health Maintenance Organizations. In lieu of hard copies, companies are required to file a Signed Jurat Page on or before March 1, 2013. The mailing address for the Signed Jurat Page is:
Commonwealth of Massachusetts
Division of Insurance
Financial Surveillance Section
1000 Washington Street, Suite 810
Boston, MA 02118-6200
Note 9
Request to File Consolidated Audited Annual Statements
Domestic Companies
Requests from domestic companies to file consolidated audited annual statements must include a statement of justification for the request (100% pooling or 100% reinsurance) and should be mailed to:
Commonwealth of Massachusetts
Division of Insurance
Financial Surveillance Section
Attention: Janine Balboni
1000 Washington Street, Suite 810
Boston, MA 02118-6200
Foreign Companies
Requests from foreign companies to file consolidated audited annual statements must include both a statement of justification for the request (100% pooling or 100% reinsurance) and copies of approvals to file consolidated audited annual statements in states of domicile for the companies in the pool; and should be mailed to:
Commonwealth of Massachusetts
Division of Insurance
Financial Surveillance Section
Attention: Janine Balboni
1000 Washington Street, Suite 810
Boston, MA 02118-6200