Annual Reporting Formats for Life and Health

 

The Annual Reporting Formats for Life and Health Section contains information on instructions, 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.

 

Small Group Health Certification Instructions and Report Template

Small Group Health Certification Instructions and Report Template

 

Long-Term Care Annual Report Forms

Long-Term Care Annual Report Forms

  • Due February 28th
     
  • Long-Term Care Survey and Contact Information for 2019 Reporting

    NEW:  Below is the NEW Long-Term Care Survey and Contact Information for 2019 Reporting Form. It replaces the hardcopy form emailed to carriers in previous reporting years. The form collects updated company information for the 2019 Reporting Year due in 2020. It compiles updated company contact information and helps in determining the level of market activity. Problems accessing the online form, please email Yolanda Fonville and request a hardcopy.
     

  • Rescission Reporting
     – Use Appendix A of NAIC Model 641
     
Medicare Supplement Annual Report Forms

Medicare Supplement Annual Report Forms

  • Due February 28th
     
  • Medicare Supplement Survey and Contact Information for 2019 Reporting
     
  • NEW:  Below is the NEW Medicare Supplement Survey and Contact Information for 2019 Reporting Form. It replaces the hardcopy form emailed to carriers in previous reporting years. The form collects updated company information for the 2019 Reporting Year due in 2020. It compiles updated company contact information and helps in determining the level of market activity. Problems accessing the online form, please email Mary Jo Wegenast and request a hardcopy.

    Medicare Supplement Survey and Contact Information for 2019 Reporting Form

     

  • Due March 1st

  • Duplication Reporting
     –  Use Appendix B of NAIC Model 651
     
  • May 31st
     
  • Refund Calculation
     – Use Appendix A of NAIC Model 651

 

Certification of Third-Party Administrator Audit

Certification of Third-Party Administrator Audit

TPA Audit Notice Regarding Certification of TPA Audit

Due July 1st

North Carolina General Assembly GS 58-56-26(c) requires every insurer shall file with the Commissioner a certification of completion of the required audits annually. 

The insurer shall submit their certification, signed by an officer of the insurer responsible for conducting such audits, as required by Title 11 NCAC 12.0332(b). You are reminded that pursuant to N.C.G.S. 58-56-26(c) records of audits conducted
are required to be maintained for a period of 5 years and are subject to examination by the Commissioner.


Pursuant to 11 NCAC 12.0332(f) - A certification template is available on this website.

 

  • The certification template is required for the purposes of consistency and efficiency.
  • This certification must be submitted via SERFF.
  • The TOI code must be ML02.000  (Multi-Line other)
  • The Filing Type must be Non-Form or Non-Rate Annual Report.

 

If you have any questions regarding this statute, or notice contact Rebecca Hill, Supervisor at Rebecca.Hill@ncdoi.gov  or 919-807-6060.

Viatical Settlement Providers & Brokers Annual Report Instructions and Report Forms

Viatical Settlement Providers & Brokers Annual Report Instructions and Report Forms

 

Viatical Settlement Annual Report Instructions

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 reportsfrom 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 reportsfrom 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 .