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 March 1st
     
  • Rescission Reporting
     – Use Appendix A of NAIC Model 641
     
Medicare Supplement Annual Report Forms

Medicare Supplement Annual Report Forms

  • 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