Life & Health

Annual Reporting Formats

Small Group Health

• 2011 Small Group Annual Activity Report Template
• Small Group Annual Actuarial Certification - Submission Instructions

Statutory Plan Elections – Election Formats

• Statutory Plan Election for Previously Approved Insurance Forms
• Statutory Plan Election for New Insurance Forms

Long-Term Care

• Rescission Reporting – Use Appendix A of NAIC Model 641
• Claims Denial Reporting – Use Appendix E of NAIC Model 641
• Replacement and Lapse Reporting – Use Appendix G of NAIC Model 641
• LTC Suitability Reporting Form
• Annual LTC Rate Stability Actuarial Certification Form – N.C.G.S. § 58-51-95(i), T11 NCAC 16.0208

Medicare Supplement

• Refund Calculation – Use Appendix A of NAIC Model 651
• Duplication Reporting – Use Appendix B of NAIC Model 651

Certification of Third Party Administrator Audit

• Notice Regarding Annual Certification of TPA Audit
• Insurer’s Certification of Third Party Administrator Audit
• Report of No Written Administrative Agreements

Viatical Settlement Providers and Viatical Settlement Brokers Annual Report

• Viatical Settlement Annual Report Instructions
• Viatical Settlement Provider Annual Reports
• Viatical Settlement Broker Annual Report