Naic Blanks (E) Working Group s3

NAIC BLANKS (E) WORKING GROUP

Blanks Agenda Item Submission Form

DATE: 01/06/2016
CONTACT PERSON:
TELEPHONE:
EMAIL ADDRESS:
ON BEHALF OF:
NAME: Kim Hudson
TITLE:
AFFILIATION: California Department of Insurance
ADDRESS: 300 South Spring St.
Los Angeles, CA 90013 / FOR NAIC USE ONLY
Agenda Item # 2016-01BWG
Year 2016
Changes to Existing Reporting [ X ]
New Reporting Requirement [ ]
REVIEWED FOR ACCOUNTING PRACTICES AND PROCEDURES IMPACT
No Impact [ X ]
Modifies Required Disclosure [ ]
DISPOSITION
[ ] Rejected For Public Comment
[ ] Referred To Another NAIC Group
[ X ] Received For Public Comment
[ ] Adopted Date
[ ] Rejected Date
[ ] Deferred Date
[ ] Other (Specify)

BLANK(S) TO WHICH PROPOSAL APPLIES

[ X ] ANNUAL STATEMENT [ X ] QUARTERLY STATEMENT

[ X ] INSTRUCTIONS [ ] CROSSCHECKS [ X ] BLANK

[ X ] Life and Accident & Health [ X ] Property/Casualty [ X ] Health

[ ] Separate Accounts [ X ] Fraternal [ X ] Title

[ ] Other Specify

Anticipated Effective Date: Annual 2016

IDENTIFICATION OF ITEM(S) TO CHANGE

Add a column to Schedule Y, Part 1A to identify Subsidiary, Controlled and Affiliates (SCAs) where a SUB 1 (initial) or SUB 2 (annual) NAIC filing is required and add an electronic only column for LEI (Legal Entity Identifier). Add a column to Schedule D, Part 6, Section 1 to identify the amount nonadmitted and separate Column 4 into two columns (NAIC Company Code & Id Number).

REASON, JUSTIFICATION FOR AND/OR BENEFIT OF CHANGE**

These columns are being added to Schedule Y, Part 1A and Schedule D, Part 6, Section 1 to aid in the verification that the SCA SUB 1 or SUB 2 NAIC filing requirements are met as required per SSAP No. 97—Investments in Subsidiary, Controlled and Affiliated Entities; and Purposes and Procedures Manual of the NAIC Investment Analysis Office Part Five, Section 2.

NAIC STAFF COMMENTS

Comment on Effective Reporting Date:

Other Comments:

** This section must be completed on all forms. Revised 6/13/2009

ANNUAL AND QUARTERLY STATEMENT INSTRUCTIONS – LIFE, HEALTH, PROPERTY, FRATERNAL & TITLE

SCHEDULE Y

PART 1A – DETAIL OF INSURANCE HOLDING COMPANY SYSTEM

All insurer and reporting entity members of the holding company system shall prepare a schedule for inclusion in each of the individual annual statements that is common for the group with the exception of Column 10, Relationship to Reporting Entity.

Detail Eliminated To Conserve Space

Column 14 – Ultimate Controlling Entity(ies)/Person(s)

Name of the Ultimate Controlling Entity(ies)/Person(s).

As defined in the Insurance Holding Company System Model Regulation (#450), the “ultimate controlling person” is defined as that person which is not controlled by any other person.

Column 15 – Is an SCA Filing Required? (Y/N)

Answer yes (Y) or no (N) if a SCA (Subsidiary, Controlled and Affiliated) SUB 1 (initial)or SUB 2 (annual) filing with the NAIC is required per SSAP No. 97—Investments in Subsidiary, Controlled and Affiliated Entities; and Purposes and Procedures Manual of the NAIC Investment Analysis Office Part Five, Section 2 for the entity in Column 8

Column 1516 – *

Using the footnote lines at the bottom of the schedule, provide any footnotes or explanations of intercompany relationships. Insert the footnote line number in Column 15.

Where interrelationships are a 50%/50% ownership, footnote any voting rights preferences that one of the entities may have.

** Column 17 will be electronic only. **

Column 17 – Legal Entity Identifier (LEI)

Provide the 20-character Legal Entity Identifier (LEI) for any issuer as assigned by a designated Local Operating Unit. If no LEI number has been assigned, leave blank.

ANNUAL STATEMENT INSTRUCTIONS – LIFE, HEALTH, PROPERTY, FRATERNAL & TITLE

SCHEDULE D – PART 6 – SECTION 1

VALUATION OF SHARES OF SUBSIDIARY, CONTROLLED OR AFFILIATED COMPANIES

Detail Eliminated To Conserve Space

Column 3 – Foreign

Insert the appropriate code in the column based on the matrix provided in the Investment Schedules General Instructions.

Column 4 – NAIC Company Code

If not applicable, the NAIC Company Code field should be zero-filled.

Column 5 – ID Number

Enter one of the following as appropriate for the entity being reported on the schedule. See the Schedule F (Property and Title) or Schedule S (Life, Health and Fraternal) General Instructions for more information on these identification numbers.

Federal Employer Identification Number (FEIN)

Alien Insurer Identification Number (AIIN) *

Certified Reinsurer Identification Number (CRIN) *

* AIINs or CRINs are only reported if the entity is a reinsurer that has had an AIIN or
CRIN number assigned or should have one assigned due to transactions being reported on Schedule F (Property and Title) or Schedule S (Life, Health and Fraternal) of another reporting entity.

If not applicable for the entity, leave blank.

Column 56 – NAIC Valuation Method

Include the NAIC valuation method as detailed in Part Five, Section 2 of the Purposes and Procedures Manual of the NAIC Investment Analysis Office.

Use the following codes to indicate a specific valuation method:

CODE Valuation Method

2ciA1 Market Value

2ciB1 Investment in US Insurance Company SCAs

2ciB2 Investments in non-insurance SCA Entities Statutory Basis

2ciB3 Investments in non-insurance SCA Entities GAAP Basis

2ciB4 Investments in Foreign Insurance Company SCA Entities

2ciB5 Investments in Foreign non-insurance SCA Entities

2ciB6 Investments in Preferred Stock of an SCA

Any NAIC Valuation Method which has not been approved by the filing of a SUB 1 form with the NAIC Securities Valuation Office and which is entered by the reporting entity under its own judgment shall have the letter “Z” appended to the method designation.

Column 67 – Do Insurer’s Assets Include Intangible Assets Connected with Holding of Such Company’s Stock?

State whether the assets shown by the reporting entity in this statement include, through the carrying value of stock of the SCA Company valued under the Purposes and Procedures Manual of the NAIC Investment Analysis Office, intangible assets arising out of the purchase of such stock by the reporting entity or the purchase by the SCA Company of the stock of a lower-tier company controlled by the SCA Company. For purposes of this question, intangible assets at purchase shall be defined as the excess of the purchase price over the tangible net worth (total assets less intangible assets and total liabilities) represented by such shares as recorded, immediately prior to the date of purchase, on the books of the company whose stock was purchased.

Column 78 – Total Amount of Such Intangible Assets

If the answer in Column 6 is “Yes,” give the total amount of intangible assets involved whether admitted or nonadmitted. The intangible assets shown for the SCA Company should include any intangible assets that are included in the SCA Company’s carrying value of the stock of one or more lower-tier companies controlled by the SCA Company. In all cases, the current intangible assets equal the intangible assets at purchase, as defined above, minus any write-off thereof between the date of purchase and the statement date. If any portion of the total amount of intangible assets is required to be nonadmitted for all SCA companies combined in accordance with SSAP No. 97, Investments in Subsidiary, Controlled, and Affiliated Entities and SSAP No. 68, Business Combinations and Goodwill, state the total amount nonadmitted in the footnote at the bottom of the this section of the schedule.

Column 10 – Nonadmitted Amount

Provide the amount nonadmitted, if any, included in Column 2 of the Asset page.

Column 911 – Stock of Such Company Owned by Insurer on Statement Date Number of Shares and

Column 1012 – Stock of Such Company Owned by Insurer on Statement Date % of Outstanding

State the number of shares of stock of the SCA Company owned by the reporting entity on the statement date and the percent owned of the outstanding shares of the same class.

** Column 11 13 will be electronic only. **

Column 1113 – Legal Entity Identifier (LEI)

Provide the 20-character Legal Entity Identifier (LEI) for any issuer as assigned by a designated Local Operating Unit. If no LEI number has been assigned, leave blank.

ANNUAL AND QUARTERLY STATEMENT BLANK – LIFE, HEALTH, PROPERTY, FRATERNAL & TITLE

SCHEDULE Y

PART 1A – DETAIL OF INSURANCE HOLDING COMPANY SYSTEM

1
Group
Code / 2
Group Name / 3
NAIC
Company
Code / 4
ID
Number / 5
Federal
RSSD / 6
CIK / 7
Name of
Securities
Exchange if
Publicly
Traded (U.S. or
International) / 8
Names of
Parent, Subsidiaries
Or Affiliates / 9
Domiciliary
Location / 10
Relationship to
Reporting
Entity / 11
Directly Controlled by
(Name of Entity/Person) / 12
Type of Control
(Ownership,
Board,
Management,
Attorney-in-Fact,
Influence, Other) / 13
If Control is
Ownership
Provide
Percentage / 14
Ultimate Controlling
Entity(ies)/Person(s) / 15
Is an SCA Filing Required? (Y/N) / 1516
*
Asterisk / Explanation

ANNUAL STATEMENT BLANK – LIFE, HEALTH, PROPERTY, FRATERNAL & TITLE

SCHEDULE D – PART 6 – SECTION 1

Valuation of Shares of Subsidiary, Controlled or Affiliated Companies

1
CUSIP
Identification / 2
Description
Name of Subsidiary,
Controlled or
Affiliated Company / 3
Foreign / 4
NAIC
Company Code
or
Alien Insurer
Identification Number / 5
ID Number / 56
NAIC
Valuation
Method
(See Purposes
and Procedures
Manual of the
NAIC
Investment
Analysis
Office) / 67
Do Insurer's Assets
Include Intangible
Assets Connected with
Holding of
Such Company's Stock? / 78
Total
Amount of Such
Intangible Assets / 89
Book /
Adjusted
Carrying
Value / 10
Nonadmitted
Amount / Stock of Such
Company Owned by
Insurer on Statement Date
911
Number
of
Shares / 1012
% of
Outstanding
1999999 Totals / XXX / XXX

1. Amount of insurer’s capital and surplus from the prior period’s statutory statement reduced by any admitted EDP, goodwill and net deferred tax assets included therein: $......

2. Total amount of intangible assets nonadmitted $

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