Annual Reporting Formats for Life and Health

The Annual Reporting Formats for Life and Health Section contains instructions, information on deadlines and forms used to report data for a specific product line or licensed entity. Submit the report in a PDF document through SERFF. If you have a question on one of the reporting forms, email the question to LHinbox@ncdoi.gov.

Tab/Accordion Items

Life and Health will no longer require Long-Term Care Annual Reporting for the following as these are now being reported on the Market Conduct Annual Statement:

  • Long-Term Care Survey and Contact Information for Annual Reporting
  • Recission Reporting
  • Claims Denial Reporting
  • Replacement and Lapse Reporting
  • LTC Suitability

Due March 15th 

Should you have questions about accessing the online form, please email Mary Jo Wegenast at MaryJo.Wegenast@ncdoi.gov.

 

Due February 28th

  • Medicare Supplement Survey and Contact Information for 2019 Reporting
  • Below is the Medicare Supplement Survey and Contact Information Form for Annual Reporting. It replaces the hardcopy form emailed to carriers in previous reporting years. The form collects updated company information for the Annual Reporting. It also helps in determining the level of market activity. Should have questions about accessing the online form, please email Paula.Lucas@ncdoi.gov.
  • Medicare Supplement Survey and Contact Information Form

Due March 1st

  • Duplication Reporting
    Use Appendix B of NAIC Model 651

May 31st

  • Refund Calculation
    – Use Appendix A of NAIC Model 651

A Third Party Administrator (TPA), as defined by NCGS 58-56-2(5) is "a person who directly or indirectly solicits or effects coverage of, underwrites, collects charges or premiums from, or adjusts or settles claims on residents of this State, or residents of another state from offices in this State, in connection with life or health insurance or annuities”. 

Annual Insurer Certification of TPA Audit - Due July 1

NCGS 58-56-26(c) requires an insurer utilizing a TPA to administer benefits for more than 100 certificate holders on behalf of the insurer, at least semiannually, to conduct an audit of the operations of the TPA. At least one semiannual audit shall be an on-site or virtual audit of the operations of the TPA. 

On July 1 each year, an insurer utilizing a TPA to administer benefits for more than 100 certificate holders on behalf of the insurer shall file with the Commissioner a certification of completion of the audits performed during the previous calendar year (reporting year). Note: NCGS 58-56-26(c) requires records of TPA audits to be maintained for a period of 5 years and such records are subject to examination by the Commissioner.  TPA audit reports are not required to be submitted to NCDOI with the annual certification. 

Insurers are required to use the TPA Audit Certification form provided in accordance with T11 NCAC 12.0332(f)  for the purposes of consistency and efficiency. Please note, in accordance with T11 NCAC 12.0332(b), the TPA Audit Certification form requires insurers to identify all TPAs with which they have a written administrative agreement per NCG 58-56-6. This includes TPAs administering benefits for more than 100 certificate holders and those TPAs not audited because they administer benefits for less than 100 certificate holders. 

  • The TPA Audit Certification shall be signed by an officer of the insurer responsible for conducting such audits, as required by T11 NCAC 12.0332(b)

  • The TPA Audit Certification must be submitted via SERFF.

  • The SERFF TOI code must be ML02.000  (Multi-Line other)

  • The SERFF Filing Type must be Annual Certification of TPA Audits.

  • Provide current, full legal name for each TPA

  • Provide accurate FEIN for each TPA

Note: NCDOI will use FEIN provided on TPA Audit Certification to confirm TPA license status when processing certification submissions.

If you have questions, please contact Rebecca Hill, Regulatory Manager, via email at Rebecca.Hill@ncdoi.gov or 919-807-6060.

Annual Insurer Report of No Written Administrative Agreements with TPAs During the Stated Reporting Period – Due July 1 

An insurer that DID NOT have any written administrative agreements during the previous calendar year (reporting year) shall as required by T11 NCAC 12.0332(g), submit a report instead of a certification. Insurers are required to use the Report to the North Carolina Department of Insurance No Written Administrative Agreements with TPAs During the Stated Reporting Period form provided in accordance with T11 NCAC 12.0332(f) for the purposes of consistency and efficiency.

If you have questions, please contact Rebecca Hill, Regulatory Manager, via email at Rebecca.Hill@ncdoi.gov or 919-807-6060.

Due June 1

Annual Reports must be emailed to LHinbox@ncdoi.gov .  If a Viatical Settlement Provider is a member of SERFF, it is preferred you file directly through SERFF.  As of March 16, 2020 we will no longer accept paper filings of the annual reports from Viatical Settlement Providers or Viatical Settlement Brokers.

Viatical Settlement Annual reports are due by June 1 reporting business from the prior calendar year, pursuant to Title 11 NCAC 12.1714. To facilitate consistency in this report please use the Viatical Settlement Provider Report Template provided below.

Viatical Settlement Providers use the reporting form from the NAIC Model Regulation. This consist of reports with the form numbers VSPB 001, VSP 002 and VSP 003. North Carolina only requires information for NC transactions and not all states.

Viatical Settlement Brokers use the reporting form from the NAIC Model Regulation. This consist of reports with the form numbers VSPB 001, VSB 002. North Carolina only requires information for NC transactions and not all states. 

If information is filed as Confidential or Trade Secret  remember to follow our guidelines at: Trade Secret Instructions 

Annual Reports must be emailed to LHinbox@ncdoi.gov .  If a Viatical Settlement Provider is a member of SERFF, it is preferred you file directly through SERFF.  As of March 16, 2020 we will no longer accept paper filings of the annual reports from Viatical Settlement Providers or Viatical Settlement Brokers.

An e-mail address to which the Commissioner can send electronic notifications and other messages must be provided.   If this email is different than the person who will be filing the renewal application, please provide this information for our records.

Include the contact person’s e-mail address who prepared this report.  If you have any questions, please contact Rebecca Hill at 919-807-6060 or Rebecca.Hill@ncdoi.gov .

 

Due Annually

Insurers who utilize illustrations to market life insurance policies are required to file annual life insurance illustration certifications with the Department pursuant to T11 NCAC 04.0509. Such submissions shall be filed through SERFF. Illustration, as defined in T11 NCAC 04.0501(8), means a presentation or depiction that includes non-guaranteed elements of a policy over a period of years and that is either a basic illustration, in-force illustration, or a supplemental illustration.

The annual due date for the life insurance illustration certification submission may be determined by the insurer per T11 NCAC 04.0509(g).

The following two items must be provided in an annual life insurance illustration certification filing:

  • From the illustration actuary per T11 NCAC 04.0509(d)(1): for all policies for which illustrations are used, detailed certification of compliance with T11 NCAC 04.0509.  A list of the illustrated forms to which the certification applies must be included.
  • From an officer of the insurer, other than the illustration actuary, per T11 NCAC 04.0509(f): certification that the illustration formats meet requirements and that the scales used in insurer-authorized illustrations are those scales certified by the illustration actuary and that the company has provided its agents with information about the expense allocation used by the company in its illustrations and disclosed as required in 11 NCAC 04.0509(c)(6).