Insurance Compliance Center

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Cedar Rapids, IA — Central Time

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MO - Insurance Producers Report (Form MO 375-0110)

Premium Tax Mail report to: Missouri Department of Insurance, Financial Institutions & Professional Registration Attn: Premium Tax Section P.O. Box 690 Jefferson City, MO 65102. State Form ID: 375-0110. StateAbbrv: MO. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Missouri Department of Insurance, Financial Institutions and Professional Regulation. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Phone: 573-526-4986 or 573-751-1929. Due by Postmark or Receive Date: Postmark. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Friday, February 10, 2012.

HI - Quarterly Net Solvency Report

State Required Filings StateAbbrv: HI. Insurance Type: Health. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Hawaii Department of Commerce and Consumer Affairs - Insurance Division. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Daniel Cheung. Contact Email: dcheung@dcca.hawaii.gov. Contact Phone: 808-587-6735. Due by Postmark or Receive Date: Receive Date. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tuesday, February 14, 2012.

MI - Report of Transaction with an Unauthorized Insurer not Recognized as Eligible (Form 0269)

Premium Tax See Checklist Link. State Form ID: 269. StateAbbrv: MI. Insurance Type: Surplus Lines. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Office of Financial and Insurance Regulation. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Phone: 517-636-6925. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Wednesday, February 15, 2012.

MI - SL Agent Semi-Annual Report of Michigan Premiums and Tax (Form FIS 0270)

Premium Tax See Checklist Link. State Form ID: FIS 0270. StateAbbrv: MI. Insurance Type: Surplus Lines. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Office of Financial and Insurance Regulation. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Phone: 517-636-6925. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Wednesday, February 15, 2012.

MN - Fire Safety Surcharge (Form IG261)

Premium Tax The fire safety surcharge is effective for insurers writing homeowners, fire and commercial nonliability policy premiums. State Form ID: IG261. StateAbbrv: MN. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Minnesota Department of Revenue. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: insurance.taxes@state.mn.us. Contact Phone: 651-556-3024. Due by Postmark or Receive Date: Postmark. Domestic/Foreign: Domestic. Foreign. Paper Size: Letter. Paper Color: White. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Wednesday, February 15, 2012.

MN - Fire Safety Surcharge for Mutual Insurance Companies (Form IG262)

Premium Tax The fire safety surcharge is effective for insurers writing homeowners, fire and commercial nonliability policy premiums. State Form ID: IG262. StateAbbrv: MN. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Minnesota Department of Revenue. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: insurance.taxes@state.mn.us. Contact Phone: 651-556-3024. Due by Postmark or Receive Date: Postmark. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Wednesday, February 15, 2012.

MN - Fire Safety Surcharge Return Payment (Form PV55 for IG261 or IG262)

Premium Tax Make check payable to Minnesota Revenue and mail to: Minnesota Revenue Mail Station 1780 St. Paul, MN 55145-1780. State Form ID: PV55. StateAbbrv: MN. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Minnesota Department of Revenue. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: insurance.taxes@state.mn.us. Contact Phone: 651-556-3024. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Wednesday, February 15, 2012.

MN - Semiannual Statement of SL Insurance (Form IG260)

Premium Tax Mail to: Minnesota Revenue Mail Station 1780 St. Paul, MN 55145-1780. State Form ID: IG260. StateAbbrv: MN. Insurance Type: Surplus Lines. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Minnesota Department of Revenue. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: nscheoeder@mnsla.com. Contact Phone: 320-679-4244. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Wednesday, February 15, 2012.

MN - SL Return Payment (Form PV53)

Premium Tax Make check payable to Minnesota Revenue and mail with Form IG260. State Form ID: PV53. StateAbbrv: MN. Insurance Type: Surplus Lines. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Minnesota Department of Revenue. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: insurance.taxes@state.mn.us. Contact Phone: 651-297-1772. Filing Method: Electronic. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Wednesday, February 15, 2012.

NE - Annual Report of SL Business

Premium Tax State Form ID: DOI_SL_ANNUAL. StateAbbrv: NE. Insurance Type: Surplus Lines. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Nebraska Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Wednesday, February 15, 2012.

NE - Quarterly Report of SL Business

Premium Tax State Form ID: DOI_SL_QUARTERLY. StateAbbrv: NE. Insurance Type: Surplus Lines. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Nebraska Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Wednesday, February 15, 2012.

CA - Disclosure of Material Transactions (Form FAD26) - Excel

State Required Filings Every 15th of the month, when applicable. All required documents must be submitted online with (OASIS) Online Assistance System for Insurer Submittal. In addition, please submit a paper copy of pages containing original signatures by the reporting deadline to: California Department of Insurance Financial Analysis Division-Financial Records 300 South Spring Street, 13th Floor, South Tower Los Angeles, CA 90013. State Form ID: FAD26. StateAbbrv: CA. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: California Department of Insurance, Financial Analysis Division - Financial Records Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Financial Records Unit. Contact Phone: 213-346-6423. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Wednesday, February 15, 2012.

HI - Drivers Education Fund Underwriters Fee Memorandum 2002-9R

State Required Filings Make checks payable to: Department of Commerce and Consumer Affairs P.O. Box 3614 Honolulu, HI 96811 Please annotate Drivers Ed Fee DEF. StateAbbrv: HI. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Hawaii Department of Commerce and Consumer Affairs - Insurance Division. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Rate & Policy Branch. Contact Email: insrpaPC@dcca.hawaii.gov. Contact Phone: 808-586-2809. Due by Postmark or Receive Date: Postmark. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Wednesday, February 15, 2012.

HI - Motor Vehicle Quarterly Report - Memorandum

State Required Filings Quarterly Reports due 45 days following the end of the quarter. To be filed by all insurers authorized to write motor vehicle insurance in Hawaii. StateAbbrv: HI. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Hawaii Department of Commerce and Consumer Affairs - Insurance Division. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Rate & Policy Branch. Contact Email: insrpaPC@dcca.hawaii.gov. Contact Phone: 808-586-2809. Due by Postmark or Receive Date: Postmark. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Wednesday, February 15, 2012.

IL - Illinois Mine Subsidence Insurance Fund

State Required Filings Mail to: Illinois Mine Subsidence Insurance Fund P.O. Box 71915 Chicago, IL 60694-1915. State Form ID: IMSIF 08-1, 08-2, 08-2L, 08-2C, 08-R. StateAbbrv: IL. Insurance Type: PC. Filing Period: Qtr 4. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Illinois Mine Subsidence Insurance Fund. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: hmweber@imsif.com. Contact Phone: 312-819-0060 Ext. 252. Due by Postmark or Receive Date: Receive. Filing Method: Electronic. Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Wednesday, February 15, 2012.

NY - Motor Vehicle Law Enforcement Fee (MVLEF)

State Required Filings Check for amount due should accompany return and be made payable to the Superintendent of Financial Services. Returns to be mailed to: Superintendent of Financial Services New York State Department of Financial Services Attn: Taxes & Accounts One Commerce Plaza Albany, New York 12257 Insurers may file and remit fees on-line through the Department website. StateAbbrv: NY. Insurance Type: PC. Filing Period: Monthly. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: New York State Department of Financial Services. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: billing@dfs.ny.gov. Contact Phone: billing@ins.state.ny.us. Due by Postmark or Receive Date: Receive Date. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Wednesday, February 15, 2012.

NY - PC Insurance Security Fund Quarterly Report

State Required Filings Returns to be mailed to: Superintendent of Financial Services New York State Department of Financial Services Bureau of Taxes and Accounts One Commerce Plaza Albany, New York 12257. StateAbbrv: NY. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: New York State Department of Financial Services. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Mark Daigneault. Contact Email: billing@dfs.ny.gov. Filing Method: Hard Copy. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Wednesday, February 15, 2012.

NY - WC Security Fund Quarterly Report

State Required Filings A check made payable to the Superintendent of Financial Services for the Workers' Compensation Security Fund of the State of New York should accompany this return and be forwarded to the Superintendent of Financial Services at the following address: Superintendent of Financial Services State of New York Insurance Department of Financial Services Bureau of Taxes and Accounts One Commerce Plaza Albany, New York 12257. State Form ID: TA-1. StateAbbrv: NY. Insurance Type: Workers Compensation. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: New York State Department of Financial Services. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Wednesday, February 15, 2012.

OR - Health Enrollment Report Form

State Required Filings This report is to be filed on a quarterly basis. Direct all inquiries to: Carla Wagner Department of Consumer & Business Services Market Surveillance-7 PO Box 14480 Salem,OR 97309-0405. StateAbbrv: OR. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Oregon Department of Consumer and Business Services, Insurance Division. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Carla Wagner. Contact Phone: 503-947-7268. Due by Postmark or Receive Date: Receive. Filing Method: Electronic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Wednesday, February 15, 2012.

OR - Health Premium Assessment Report

State Required Filings The Health Premium Assessment Report must be filed on-line with the Oregon Insurance Division within 45 days after the end of every calendar quarter. This is a new assessment that became effective 10/1/2009 and applies to all insurers authorized in Oregon for health insurance. StateAbbrv: OR. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Oregon Department of Consumer and Business Services, Insurance Division. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Lynette Hadley Shannon O'Shea. Contact Email: OrInstax@state.or.us. Contact Phone: 503-947-7046 503-947-7218. Due by Postmark or Receive Date: Postmark. Filing Method: Electronic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Wednesday, February 15, 2012.

OR - WC Premium Assessment Report

State Required Filings File Form 440-910 and the premium assessment payment with: DCBS Fiscal and Business Services P.O. Box 14610 Salem, OR 97309-0445. State Form ID: 440-910. StateAbbrv: OR. Insurance Type: Workers Compensation. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Oregon Department of Consumer and Business Services, Workers' Compensation Division. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Premium Assessment Senior Accountant. Contact Email: wbfassess.fabs@state.or.us. Contact Phone: 503-947-7941. Due by Postmark or Receive Date: Postmark. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Wednesday, February 15, 2012.

SD - Risk Pool Report of Covered Lives

State Required Filings Return to: Division of Insurance 445 E. Capitol Avenue Pierre, SD 57501 OR Fax: 605-773-5369 or email Melissa.klemann@state.sd.us. OR email: tammy.johnson@state.sd.us OR fax: 605-773-5369 DO NOT send a payment with this form. StateAbbrv: SD. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: South Dakota Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Tammy Johnson. Contact Email: sdinsurancereports@state.sd.us. Contact Phone: 605-773-3563. Filing Method: Electronic. Hard Copy. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Wednesday, February 15, 2012.

TX - Call for Fourth Quarter WC Experience Bulletin Form

State Required Filings How to file: PDF Format Hardcopy filings no longer accepted. StateAbbrv: TX. Insurance Type: PC. Reinsurance. Workers Compensation. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Texas Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: ChiefClerk@tdi.state.tx.us. Contact Phone: 512-475-3030. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Wednesday, February 15, 2012.

UT - Renewal Instructions - RRG

State Required Filings You must pay your renewal fees electronically through the department's secure payment portal using either a credit card or an electronic check. Please email your completed Risk Retention Group renewal documents and a copy of your annual premium tax report to Brad Tibbots at btibbits@utah.gov. StateAbbrv: UT. Insurance Type: Risk Retention Group. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Utah Insurance Department. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Brad Tibbitts. Contact Email: btibbitts@utah.gov. Contact Phone: 801-537-9177. Due by Postmark or Receive Date: Receive. Filing Method: Electronic. Payment Method: You must pay your renewal fees electronically through the department's secure payment portal using either a credit card or an electronic check. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Wednesday, February 15, 2012.

UT - Renewal Instructions - SL

State Required Filings Renewal fees must be paid electronically. Alien insurers only - Please email the date your annual statement is required to be filed by your domiciliary authority to Beth Crim at bcrim@utah.gov. StateAbbrv: UT. Insurance Type: Surplus Lines. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Utah Insurance Department. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Beth Crim. Contact Email: bcrim@utah.gov. Due by Postmark or Receive Date: Receive. Filing Method: Electronic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Wednesday, February 15, 2012.

WI - Annual Actuarial Filing Request

State Required Filings StateAbbrv: WI. Insurance Type: Health. LAH. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Wisconsin Office of the Commissioner of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Yvonne Sherry. Contact Email: yvonne.sherry@wisconsin.gov. Contact Phone: 608-266-0091. Due by Postmark or Receive Date: Receive. Filing Method: Hard Copy. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Wednesday, February 15, 2012.

GU - Monthly Gross Receipts Use and Occupancy Tax Return (Form GRT-1)

Premium Tax The monthly return shall be filed and any tax then due shall be paid no later than the twentieth day of the following month. You may file your GRT form by mail at the following address: Department of Revenue and Taxation Taxpayer Services Division P.O. Box 23607 GMF, Guam 96921 Express Mail or In Person: Guam Department of Revenue and Taxation Business Privilege Tax Branch 1240 Route 16 Barrigada, Guam. StateAbbrv: GU. Filing Period: Monthly. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Department of Revenue and Taxation. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: grt@revtax.gov.gu. Contact Phone: 671-635-1835/6. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Monday, February 20, 2012.

HI - Premium Tax Statement - Monthly (Form 323)

Premium Tax See Checklist Link. State Form ID: Form 323. StateAbbrv: HI. Insurance Type: Health. LAH. PC. Filing Period: Monthly. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: State of Hawaii Department of Commerce and Consumer Affairs, Insurance Division. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: shansen@dcca.hawaii.gov. Contact Phone: 808-586-7381. Due by Postmark or Receive Date: Postmark. Paper Size: Letter. Paper Color: White. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Monday, February 20, 2012.

KY - Monthly Insurance Surcharge Report - Domestic Mutual Cooperative and Assessment Fire (Form 74A117)

Premium Tax Make check payable to Kentucky State Treasurer and mail return with payment to: Kentucky Department of Revenue P.O. Box 1303 Frankfort, KY 40602-1303 Overnight Address:Kentucky Department of Revenue 501 High Street Frankfort, KY 40601. State Form ID: 74A117. StateAbbrv: KY. Insurance Type: PC. Filing Period: Monthly. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Commonwealth of Kentucky, Department of Revenue. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Phone: 502-564-4810. Due by Postmark or Receive Date: Receive. Payment Method: Check. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Monday, February 20, 2012.

KY - Monthly Insurance Surcharge Report (Form 74A118)

Premium Tax Make check payable to Kentucky State Treasurer and mail return with payment to: Kentucky Department of Revenue P.O. Box 1303 Frankfort, KY 40602-1303 Overnight Address:Kentucky Department of Revenue 501 High Street Frankfort, KY 40601. State Form ID: 74A118. StateAbbrv: KY. Insurance Type: PC. Filing Period: Monthly. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Commonwealth of Kentucky, Department of Revenue. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Phone: 502-564-4810. Due by Postmark or Receive Date: Receive. Payment Method: Check. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Monday, February 20, 2012.

VT - Insurance Premium Tax Return - Captive (Form IP-2)

Premium Tax If sending via US Mail: VT Department of Taxes PO Box 547 Montpelier, VT 05601-0547 If sending via courier service: VT Department of Taxes 133 State Street Montpelier, VT 05633-1401. State Form ID: IP-2. StateAbbrv: VT. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Vermont Department of Taxes. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Phone: 802-828-2551 Option 4. Domestic/Foreign: Domestic. Foreign. Paper Size: Letter. Paper Color: White. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tuesday, February 28, 2012.

VT - Insurance Premium Tax Return (Form IP-1)

Premium Tax State Form ID: IP-1. StateAbbrv: VT. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Vermont Department of Taxes. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Phone: 802-828-2551 Option 4. Domestic/Foreign: Domestic. Foreign. Paper Size: Letter. Paper Color: White. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tuesday, February 28, 2012.

WV - Statement of Premiums - RPG

Premium Tax Mailing Address: P.O. Box 50542 Charleston, WV 25305-0542. StateAbbrv: WV. Insurance Type: Risk Purchasing Group. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: West Virginia Insurance Commissioner. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: wvtaxsection@wvinsurance.gov. Contact Phone: 304-558-2100. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tuesday, February 28, 2012.

AR - Accredited Reinsurer Renewal Information

State Required Filings Submit application to: Arkansas Insurance Department Finance Division 1200 West Third Street Little Rock, AR 72201-1904. StateAbbrv: AR. Insurance Type: Reinsurance. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arkansas Insurance Department. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Phone: 501-371-2665. Filing Method: Hard Copy. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tuesday, February 28, 2012.

AR - Trusteed Reinsurer Renewal Information

AZ - Qualified Reinsurer Annual Statement Worksheet (Form E-QRT.AS)

State Required Filings Your Qualified Reinsurer status may be suspended or terminated if you do not comply with financial statement filing requirements. State Form ID: E-QRT.AS. StateAbbrv: AZ. Insurance Type: Reinsurance. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arizona Department of Insurance, Insurance Tax Unit - Compliance Section. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Compliance Section. Contact Phone: 602-364-3245. Due by Postmark or Receive Date: Postmark. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tuesday, February 28, 2012.

FL - Premium Growth Report (Form OIR-A1-1229)

State Required Filings State Form ID: OIR-A1-1229. StateAbbrv: FL. Insurance Type: PC. Filing Period: Monthly. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Florida Office of Insurance Regulation. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Helen Westberry. Contact Email: Helen.Westberry@floir.com. Contact Phone: 850-413-5212. Filing Method: Electronic. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tuesday, February 28, 2012.

ID - Continuation Fee Statement - Trusteed Reinsurer

State Required Filings State Form ID: INS-PTX-FTRST. StateAbbrv: ID. Insurance Type: Reinsurance. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Idaho Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tuesday, February 28, 2012.

VT - Domestic RRG and Association Captives Checklist

State Required Filings StateAbbrv: VT. Insurance Type: Risk Retention Group. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Vermont Insurance Division - Department of Banking, Insurance, Securities and Health Care Administration. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Company Licensing Section. Contact Email: bishca.complic@state.vt.us. Contact Phone: 802-828-3304. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tuesday, February 28, 2012.

VT - Foreign RRG and RPG Checklist

State Required Filings StateAbbrv: VT. Insurance Type: Risk Purchasing Group. Risk Retention Group. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Vermont Insurance Division - Department of Banking, Insurance, Securities and Health Care Administration. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Company Licensing Section. Contact Email: bishca.complic@state.vt.us. Contact Phone: 802-828-3301. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tuesday, February 28, 2012.

AK - Annual Premium Tax Payment

Premium Tax If the annual premium tax payment is not received in the State of Alaska's bank on or before March 1, a late fee will be assessed. If payment is not received by ACH, a penalty will be assessed. StateAbbrv: AK. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Alaska Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: rebecca.nesheim@alaska.gov. Contact Phone: 907-465-2584. Due by Postmark or Receive Date: Postmark. Filing Method: Electronic. Payment Method: ACH. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AK - Health Annual Premium Tax Report (Form 08-201H)

Premium Tax Reminder: State Page and Schedule T - One copy of each to be filed with Annual Premium Tax Report. First Class Mail (including Registered and Certified): Alaska Division of Insurance P.O. Box 110805 Juneau, AK 99811-0805. State Form ID: 08-201H. StateAbbrv: AK. Insurance Type: Health. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Alaska Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: rebecca.nesheim@alaska.gov. Contact Phone: 907-465-2584. Due by Postmark or Receive Date: Postmark. Domestic/Foreign: Domestic. Foreign. Paper Color: Blue. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AK - HMSC Annual Premium Tax Report - Domestic (Form 08-201D)

Premium Tax First Class Delivery: Alaska Division of Insurance PO Box 110805 Juneau, AK 99811. State Form ID: 08-201D. StateAbbrv: AK. Insurance Type: Health. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Alaska Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: rebecca.nesheim@alaska.gov. Contact Phone: 907-465-2584. Due by Postmark or Receive Date: Postmark. Domestic/Foreign: Domestic. Paper Color: Blue. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AK - HMSC Annual Premium Tax Report (Form 08-201HM)

Premium Tax First Class Mail: (including Registered and Certified) Alaska Division of Insurance P.O. Box 110805 Juneau, AK 99811-0805. State Form ID: 08-201HM. StateAbbrv: AK. Insurance Type: Health. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Alaska Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: rebecca.nesheim@alaska.gov. Contact Phone: 907-465-2584. Due by Postmark or Receive Date: Postmark. Domestic/Foreign: Domestic. Foreign. Paper Color: Blue. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AK - LAH Annual Premium Tax Report (Form 08-201L)

Premium Tax Reminder: State Page and Schedule T - One copy of each to be filed with Annual Premium Tax Report. First Class Mail (including Registered and Certified): Alaska Division of Insurance P.O. Box 110805 Juneau, AK 99811-0805. State Form ID: 08-201L. StateAbbrv: AK. Insurance Type: LAH. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Alaska Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: rebecca.nesheim@alaska.gov. Contact Phone: 907-465-2584. Due by Postmark or Receive Date: Postmark. Domestic/Foreign: Domestic. Foreign. Paper Size: Letter. Paper Color: White. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AK - PC Annual Premium Tax Report - Domestic (Form 08-200D)

Premium Tax First Class Delivery: Alaska Division of Insurance PO Box 110805 Juneau, AK 99811. State Form ID: 08-200D INS. StateAbbrv: AK. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Alaska Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: rebecca.nesheim@alaska.gov. Contact Phone: 907-465-2584. Due by Postmark or Receive Date: Postmark. Domestic/Foreign: Domestic. Paper Size: Letter. Paper Color: White. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AK - PC Annual Premium Tax Report (Form 08-200)

Premium Tax Reminder: State Page and Schedule T - One copy of each to be filed with Annual Premium Tax Report. First Class Mail (including Registered and Certified): Alaska Division of Insurance P.O. Box 110805 Juneau, AK 99811-0805. State Form ID: 08-200 INS. StateAbbrv: AK. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Alaska Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: rebecca.nesheim@alaska.gov. Contact Phone: 907-465-2584. Due by Postmark or Receive Date: Postmark. Domestic/Foreign: Foreign. Paper Size: Letter. Paper Color: White. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AK - RRG Tax Packet (Form 08-203RRG)

Premium Tax First Class Mail: (including Registered and Certified) Alaska Division of Insurance P.O. Box 110805 Juneau, AK 99811-0805. State Form ID: 08-203RRG. StateAbbrv: AK. Insurance Type: Risk Retention Group. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Alaska Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: rebecca.nesheim@alaska.gov. Contact Phone: 907-465-2584. Due by Postmark or Receive Date: Postmark. Domestic/Foreign: Domestic. Foreign. Paper Size: Letter. Paper Color: White. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AK - Unauthorized Insurers Tax Form (Form 08-1240)

Premium Tax First Class Mail: (including Registered and Certified) Alaska Division of Insurance P.O. Box 110805 Juneau, AK 99811-0805. State Form ID: 08-1240. StateAbbrv: AK. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Alaska Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: rebecca.nesheim@alaska.gov. Contact Phone: 907-465-2584. Due by Postmark or Receive Date: Postmark. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - Audit & Exam Transmittal Form

Premium Tax All Companies licensed in the State of Alabama must pay the Annual Audit and Examination Fee of $850.00. The only exceptions are Mutual Aid Associations, Fraternal Benefits societies, and HMOs. The Fee for Mutual Aids and Fraternals is $225 and the fee for HMOs is $300. Surplus line insurers doing business in Alabama must pay the Annual Audit and Examination Fee of $850. Postal Service: Alabama Department of Insurance c/o Compass Bank P.O. Box 830707 Birmingham, AL 35283-0707. State Form ID: PR. StateAbbrv: AL. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: ann.strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive. Payment Method: Check payable to : Alabama Department of Insurance. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - Captive Insurer Tax Form

Premium Tax StateAbbrv: AL. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: ann.strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - Credit Allocation Worksheet

Premium Tax Each company taking a percentage of the credit must attach this form to its annual premium tax return. StateAbbrv: AL. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: ann.strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - Documentation for Premium Tax Return

Premium Tax All premium tax credits/deductions taken on the annual premium tax return should be documented with copies of cancelled checks and privilege tax returns (1st page only), ad valorem tax notices, guaranty fund and Alabama Health Insurance Plan assessment notices, invoices. Premiums which are taxed at less than the maximum should be documented with detailed policy runs. Documentation should be emailed to premiumtax@insurance.alabama.gov. The subject line of the email must have the name of the company and the year. StateAbbrv: AL. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: ann.strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - Domestic HMO Annual

Premium Tax Postal Service: Alabama Department of Insurance c/o Compass Bank P.O. Box 830691 Birmingham, AL 35283-0691. State Form ID: PA-G. StateAbbrv: AL. Insurance Type: Health. HMO. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: ann.strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - Domestic LAH Annual

Premium Tax All premium tax credits/deductions taken on the annual premium tax return should be documented with copies of cancelled checks and privilege tax returns (1st page only), ad valorem tax notices, guaranty fund and Alabama Health Insurance Plan assessment notices, invoices. Premiums which are taxed at less than the maximum should be documented with detailed policy runs. Documentation should be emailed to premiumtax@insurance.alabama.gov. The subject line of the email must have the name of the company and the year. State Form ID: PA-B. StateAbbrv: AL. Insurance Type: LAH. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: ann.strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Domestic. Paper Size: Letter. Paper Color: White. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - Domestic PC Annual

Premium Tax All premium tax credits/deductions taken on the annual premium tax return should be documented with copies of cancelled checks and privilege tax returns (1st page only), ad valorem tax notices, guaranty fund and Alabama Health Insurance Plan assessment notices, invoices. Premiums which are taxed at less than the maximum should be documented with detailed policy runs. Documentation should be emailed to premiumtax@insurance.alabama.gov. The subject line of the email must have the name of the company and the year. State Form ID: PB-Y. StateAbbrv: AL. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: ann.strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Domestic. Paper Size: Letter. Paper Color: White. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - Foreign Casualty Annual

Premium Tax All premium tax credits/deductions taken on the annual premium tax return should be documented with copies of cancelled checks and privilege tax returns (1st page only), ad valorem tax notices, guaranty fund and Alabama Health Insurance Plan assessment notices, invoices. Premiums which are taxed at less than the maximum should be documented with detailed policy runs. Documentation should be emailed to premiumtax@insurance.alabama.gov. The subject line of the email must have the name of the company and the year. State Form ID: PF-Y. StateAbbrv: AL. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: ann.strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Foreign. Paper Size: Letter. Paper Color: White. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - Foreign HMO Annual

Premium Tax Postal Service: Alabama Department of Insurance c/o Compass Bank P.O. Box 830691 Birmingham, AL 35283-0691. State Form ID: PD-G. StateAbbrv: AL. Insurance Type: Health. HMO. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: ann.strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - Foreign LAH Annual

Premium Tax All premium tax credits/deductions taken on the annual premium tax return should be documented with copies of cancelled checks and privilege tax returns (1st page only), ad valorem tax notices, guaranty fund and Alabama Health Insurance Plan assessment notices, invoices. Premiums which are taxed at less than the maximum should be documented with detailed policy runs. Documentation should be emailed to premiumtax@insurance.alabama.gov. The subject line of the email must have the name of the company and the year. State Form ID: PD-B. StateAbbrv: AL. Insurance Type: LAH. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: ann.strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Foreign. Paper Size: Letter. Paper Color: White. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - Foreign Property Annual

Premium Tax All premium tax credits/deductions taken on the annual premium tax return should be documented with copies of cancelled checks and privilege tax returns (1st page only), ad valorem tax notices, guaranty fund and Alabama Health Insurance Plan assessment notices, invoices. Premiums which are taxed at less than the maximum should be documented with detailed policy runs. Documentation should be emailed to premiumtax@insurance.alabama.gov. The subject line of the email must have the name of the company and the year. State Form ID: PE-Y. StateAbbrv: AL. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: ann.strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Foreign. Paper Size: Letter. Paper Color: White. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - Offices Facilities Credit Worksheet

Premium Tax The worksheet should be filed only if credit is taken. StateAbbrv: AL. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: ann.strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - Retaliatory Tax Statement

Premium Tax Postal Service: Alabama Department of Insurance c/o Compass Bank P.O. Box 830691 Birmingham, AL 35283-0691. State Form ID: PG. StateAbbrv: AL. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: ann.strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - Risk Retention Companies Annual

Premium Tax Postal Service: Alabama Department of Insurance c/o Compass Bank P.O. Box 830691 Birmingham, AL 35283-0691. State Form ID: RR-W. StateAbbrv: AL. Insurance Type: Risk Retention Group. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: ann.strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Domestic. Foreign. Paper Size: Letter. Paper Color: White. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AR - Annual Continuation Filing Fee - Approved Foreign SL Insurers (Form AID AC SLI-T)

Premium Tax State Form ID: AID AC SLI-T. StateAbbrv: AR. Insurance Type: PC. Surplus Lines. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Arkansas Insurance Department, Accounting Division. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: insurance.accounting@arkansas.gov. Contact Phone: 501-371-2605. Due by Postmark or Receive Date: Receive. Payment Method: Check payable to: The State Insurance Department Trust Fund. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AR - Annual Report of Premiums and Taxes - Captive (Form AID AC CI-T)

Premium Tax DO NOT include Corporate Franchise Tax with the premium tax filings. Mail the return, documentation, and check to: Arkansas Insurance Department Accounting Division 1200 West Third Street Little Rock, AR 72201-1904. State Form ID: AID AC CI-T. StateAbbrv: AR. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arkansas Insurance Department. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Accounting Division. Contact Email: insurance.accounting@arkansas.gov. Contact Phone: 501-371-2605. Due by Postmark or Receive Date: Receive Date. Filing Method: Hard Copy. Payment Method: Check payable to State Treasurer of Arkansas. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AR - Annual Report of Premiums and Taxes - FPRF (Form AID AC FPRF)

Premium Tax State Form ID: AID AC FPRF. StateAbbrv: AR. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Arkansas Insurance Department, Accounting Division. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: insurance.accounting@arkansas.gov. Contact Phone: 501-371-2605. Due by Postmark or Receive Date: Receive. Payment Method: Check payable to: The Fire Protection Premium Tax Fund. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AR - Annual Report of Premiums Copayments Taxes and Fees - HMO (Form AID AC HMO-T)

Premium Tax State Form ID: AID AC HMO-T, IC-PT. StateAbbrv: AR. Insurance Type: Health. HMO. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Arkansas Insurance Department, Accounting Division. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: insurance.accounting@arkansas.gov. Contact Phone: 501-371-2605. Due by Postmark or Receive Date: Receive. Payment Method: CHECK PAYABLE TO: THE STATE TREASURER. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AR - Annual Report of Premiums Copayments Taxes and Fees - HMSC (Form AID AC HM-T)

Premium Tax State Form ID: AID AC HM-T. StateAbbrv: AR. Insurance Type: Health. Filing Period: Annual, Qtr 4. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Arkansas Insurance Department, Accounting Division. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: insurance.accounting@arkansas.gov. Contact Phone: 501-371-2605. Due by Postmark or Receive Date: Receive. Payment Method: CHECK PAYABLE TO: THE STATE TREASURER. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AR - Annual Report of Premiums Taxes and Fees - Domestic LAH (Form AID AC LD-TD)

Premium Tax State Form ID: AID AC LD-T(D). StateAbbrv: AR. Insurance Type: Health. LAH. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Arkansas Insurance Department, Accounting Division. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: insurance.accounting@arkansas.gov. Contact Phone: 501-371-2605. Due by Postmark or Receive Date: Receive. Payment Method: Check payable to: The State Treasurer of the State of Arkansas. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AR - Annual Report of Premiums Taxes and Fees - Domestic PC (Form AID AC PC-TD)

Premium Tax State Form ID: AID AC PC-T(D). StateAbbrv: AR. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Arkansas Insurance Department, Accounting Division. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: insurance.accounting@arkansas.gov. Contact Phone: 501-371-2605. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AR - Annual Report of Premiums Taxes and Fees - Foreign LAH (AID AC LD-T)

Premium Tax State Form ID: AID AC LD-T. StateAbbrv: AR. Insurance Type: LAH. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Arkansas Insurance Department, Accounting Division. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: insurance.accounting@arkansas.gov. Contact Phone: 501-371-2605. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Foreign. Paper Size: 8 1/2 x 11. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AR - Annual Report of Premiums Taxes and Fees - Foreign PC (Form AID AC PC-T)

Premium Tax State Form ID: AID AC PC-T. StateAbbrv: AR. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Arkansas Insurance Department, Accounting Division. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: insurance.accounting@arkansas.gov. Contact Phone: 501-371-2605. Due by Postmark or Receive Date: Receive. Payment Method: Check payable to: The State Insurance Department Trust Fund. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AR - Annual Report of Premiums Taxes and Fees - Registered RRG (Form AID AC RRG-T)

Premium Tax State Form ID: AID AC RRG-T. StateAbbrv: AR. Insurance Type: Risk Retention Group. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Arkansas Insurance Department, Accounting Division. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: insurance.accounting@arkansas.gov. Contact Phone: 501-371-2605. Due by Postmark or Receive Date: Receive. Payment Method: CHECK PAYABLE TO: THE STATE TREASURER. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AR - Insurance Carrier Worksheet for WC Premium Taxes

Premium Tax StateAbbrv: AR. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Arkansas Workers' Compensation Commission. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: lcampbell@awcc.state.ar.us or agarmon@awcc.state.ar.us. Contact Phone: 501-682-2737 or 501-682-1494. Due by Postmark or Receive Date: Receive. Payment Method: Checks payable to: Arkansas Workers' Compensation Commission. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - Accountable Health Plan Small Group Premiums (Form E-AHP)

Premium Tax Only file this schedule if you are approved in Arizona as an accountable health plan and are claiming a small group premium exemption on Annual Tax and Fees Report. If you are filing your premium tax report electronically, attach the completed spreadsheet to your OPTins filing. If you file a hard copy tax report, provide this spreadsheet on a CD-ROM labeled with your name and NAIC number, or call us for e-mail instructions. State Form ID: E-AHP. StateAbbrv: AZ. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: State of Arizona, Insurance Tax Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: sgreenberg@azinsurance.gov. Contact Phone: 602-364-3997. Domestic/Foreign: Domestic. Foreign. Paper Size: Letter. Paper Color: White. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - Annual Fees Report (Form E-ANNUALFEES)

Premium Tax Make your check payable to Arizona Insurance Tax Unit, print your NAIC number in the memo section. Do not mail this form or payment with your annual statement. State Form ID: E-ANNUALFEES. StateAbbrv: AZ. Insurance Type: Reinsurance. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: State of Arizona, Insurance Tax Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: sgreenberg@azinsurance.gov. Contact Phone: 602-364-3997. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - Annual Tax and Fees Report - Health Organization (Form E-HEALTHORG)

Premium Tax Do not mail this form or your payment inside your Annual Statement package. Mail your check with this report separately to: Arizona Insurance Tax Unit 2910 North 44th Street, Suite 210 Phoenix, AZ 85018-7269. State Form ID: E-HEALTHORG. StateAbbrv: AZ. Insurance Type: Health. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: State of Arizona, Insurance Tax Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: sgreenberg@azinsurance.gov. Contact Phone: 602-364-3997. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - Annual Tax and Fees Report - Life and Disability (Form E-LD)

Premium Tax Do not mail this form or your payment inside your Annual Statement package. Mail your check with this report separately to: Arizona Insurance Tax Unit 2910 North 44th Street, Suite 210 Phoenix, AZ 85018-7269. State Form ID: E-LD. StateAbbrv: AZ. Insurance Type: LAH. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: State of Arizona, Insurance Tax Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: sgreenberg@azinsurance.gov. Contact Phone: 602-364-3997. Due by Postmark or Receive Date: Postmark. Domestic/Foreign: Domestic. Foreign. Paper Size: Letter. Paper Color: White. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - Annual Tax and Fees Report - PC (Form E-PC)

Premium Tax Do not mail this form or your payment inside your Annual Statement package. Mail your check with this report separately to: Arizona Insurance Tax Unit 2910 North 44th Street, Suite 210 Phoenix, AZ 85018-7269. State Form ID: E-PC. StateAbbrv: AZ. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: State of Arizona, Insurance Tax Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: sgreenberg@azinsurance.gov. Contact Phone: 602-364-3997. Due by Postmark or Receive Date: Postmark. Domestic/Foreign: Domestic. Foreign. Paper Size: Letter. Paper Color: White. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - Annual Tax Report - Foreign RRG (Form E-RG)

Premium Tax Do not mail this form or your payment inside your Annual Statement package. Mail your check with this report separately to: Arizona Insurance Tax Unit 2910 North 44th Street, Suite 210 Phoenix, AZ 85018-7269. State Form ID: E-RG. StateAbbrv: AZ. Insurance Type: Risk Retention Group. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: State of Arizona, Insurance Tax Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: sgreenberg@azinsurance.gov. Contact Phone: 602-364-3997. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - HMDO Exempt Government Premiums (Form E-HEALTHORG.HMDO)

Premium Tax State Form ID: E-HEALTHORG.HMDO. StateAbbrv: AZ. Insurance Type: Health. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: State of Arizona, Insurance Tax Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: sgreenberg@azinsurance.gov. Contact Phone: 602-364-3997. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - ICA Administrative and Special Funds Premium Tax Form (Form 200)

Premium Tax Please return completed form with a copy of "Statutory Page 14 - Exhibit of Premiums and Losses of the Annual Report" with your check, payable to the Industrial Commission of Arizona, and mail to: Industrial Commission of Arizona Attention: Tax Accountant 800 West Washington Street, Room 301 Phoenix, AZ 85007. State Form ID: 200. StateAbbrv: AZ. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Industrial Commission of Arizona. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: taxes@ica.state.az.us. Contact Phone: 602-542-1836. Due by Postmark or Receive Date: Postmark. Payment Method: Check made payable to Industrial Commission of Arizona. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - ICA Administrative Fund Premium Tax Form (Form 200B)

Premium Tax Mail completed form to: Industrial Commission of Arizona Attention: Tax Accountant 800 West Washington Street, Room 301 Phoenix, Arizona 85007. State Form ID: 200B. StateAbbrv: AZ. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Industrial Commission of Arizona. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: Taxes@ica.state.az.us. Contact Phone: 602-542-1836. Due by Postmark or Receive Date: Postmark. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - ICA Special Fund Premium Tax Form (Form 200A)

Premium Tax Mail completed form to: Industrial Commission of Arizona Attention: Tax Accountant 800 West Washington Street, Room 301 Phoenix, Arizona 85007. State Form ID: 200A. StateAbbrv: AZ. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Industrial Commission of Arizona. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: Taxes@ica.state.az.us. Contact Phone: 602-542-1836. Due by Postmark or Receive Date: Postmark. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - Local and Regional Taxes and Fees Payments - Domestic Insurers (Form E-LRTF)

Premium Tax Arizona requires each domestic insurer to complete a Survey of Arizona Domestic Insurers as part of its Annual Premium Tax and Fees Report. You must provide all completed survey documents and spreadsheets electronically, either as attachments to an OPTins filing or on a CD-ROM. State Form ID: E-LRTF. StateAbbrv: AZ. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Arizona Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Phone: 602-364-3764. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - SL Claim for Refund (Form E-173SLB)

Premium Tax This form must be filed with a Form E-SL-1, Form E-SL-2, Form E-SL-AMEND or Form E-159MS tax report that shows a negative tax amount due to claim a tax refund for a prior period. State Form ID: E-173SLB. StateAbbrv: AZ. Insurance Type: Surplus Lines. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: The Surplus Line Association of Arizona. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Phone: 602-364-3246. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - SL Semi-Annual Tax Report

Premium Tax Log in to the Surplus Lines Association of Arizona web site to print your tax report. State Form ID: E-SL-2. StateAbbrv: AZ. Insurance Type: Surplus Lines. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: The Surplus Line Association of Arizona. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Phone: 602-364-3246. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - Statement and Tax Payment for the AZ Portion of a Multi State SL Transaction (Form E-159MS)

Premium Tax The tax payment must be payable to the Arizona Insurance Tax Unit and must accompany the report Form E-159MS. Do not send checks and reports separately. State Form ID: E-159MS. StateAbbrv: AZ. Insurance Type: Surplus Lines. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: State of Arizona, Insurance Tax Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: sgreenberg@azinsurance.gov. Contact Phone: 602-364-3997. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - Survey of Arizona Domestic Insurers

Premium Tax This survey is required to be filed with your Annual Premium Tax and Fees Report Form. State Form ID: E-SURVEY. StateAbbrv: AZ. Insurance Type: LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: State of Arizona, Insurance Tax Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: sgreenberg@azinsurance.gov. Contact Phone: 602-364-3997. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CO - Premium Taxes Homepage

Premium Tax See Checklist Link. StateAbbrv: CO. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Colorado Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: copremiumtax@dora.state.co.us. Due by Postmark or Receive Date: Receive Date. Filing Method: Electronic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CT - Application for Extension of Time to File - Domestic or HCC Tax Return (Form 207-207 HCC EXT)

Premium Tax Complete this return in blue or black ink only. Make check payable to: Commissioner of Revenue Services. Mail to: Department of Revenue Services State of Connecticut PO Box 2990 Hartford, CT 06104-2990. State Form ID: 207-207 HCC EXT. StateAbbrv: CT. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Department of Revenue Services, State of Connecticut. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Phone: 860-297-5962. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CT - Application for Extension of Time to File - Nonresident and Foreign Tax Return (Form 207F EXT)

Premium Tax Complete this return in blue or black ink only. Complete this return in blue or black ink only. Make checks payable to: Commissioner of Revenue Services. Mail to: Department of Revenue Services State of Connecticut PO Box 2990 Hartford, CT 06104-2990. State Form ID: 207F EXT. StateAbbrv: CT. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Department of Revenue Services, State of Connecticut. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Phone: 860-297-5962. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CT - HCC Tax Return (Form 207 HCC)

Premium Tax Complete this return in blue or black ink only. Make checks payable to: Commissioner of Revenue Services. Mail to: Department of Revenue Services State of Connecticut PO Box 2990 Hartford, CT 06104-2990. State Form ID: 207 HCC. StateAbbrv: CT. Insurance Type: Health. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Department of Revenue Services, State of Connecticut. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Phone: 860-297-5962. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CT - Insurance Premiums Tax Return - Domestic (Form 207)

Premium Tax Complete this return in blue or black ink only. Make checks payable to: Commissioner of Revenue Services. Mail to: Department of Revenue Services State of Connecticut PO Box 2990 Hartford, CT 06104-2990. State Form ID: Form 207. StateAbbrv: CT. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Department of Revenue Services, State of Connecticut. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Phone: 860-297-5962. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Domestic. Paper Size: Letter. Paper Color: White. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CT - Insurance Premiums Tax Return - Nonresident and Foreign (Form 207F)

Premium Tax Complete this return in blue or black ink only. Make checks payable to: Commissioner of Revenue Services. Mail to: Department of Revenue Services State of Connecticut PO Box 2990 Hartford, CT 06104-2990. State Form ID: Form 207F. StateAbbrv: CT. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Tax Filing Requirements: http://www.eagletm.com/Documentation/TaxFilingRequirements/2011/index.html. State Authority: Department of Revenue Services, State of Connecticut. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Phone: 860-297-5962. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Foreign. Paper Size: Letter. Paper Color: White. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AK - Certificate of Assuming Insurer (Form 08-238)

State Required Filings As an accredited reinsurer with our state, we ask that you please make the notation Accredited Reinsurer on all correspondence and filings with our office. Please mail to: Financial Examination Section Alaska Division of Insurance 550 West 7th Avenue, Suite 1560 Anchorage, AK 99501-3567. State Form ID: 08-238. StateAbbrv: AK. Insurance Type: Reinsurance. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Alaska Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Rebecca Nesheim, Tax Auditor. Contact Email: rebecca.nesheim@alaska.gov. Contact Phone: 907-465-2584. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AK - Certificate of Compliance

State Required Filings File with Annual Premium Tax Report or separately. StateAbbrv: AK. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Alaska Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Rebecca Nesheim, Tax Auditor. Contact Email: rebecca.nesheim@alaska.gov. Contact Phone: 907-465-2584. Due by Postmark or Receive Date: Postmark. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AK - Certificate of Deposit

State Required Filings File with Annual Premium Tax Report or separately. StateAbbrv: AK. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Alaska Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Rebecca Nesheim, Tax Auditor. Contact Email: rebecca.nesheim@alaska.gov. Contact Phone: 907-465-2584. Due by Postmark or Receive Date: Postmark. Filing Method: Hard Copy. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AK - Certificate of Valuation

State Required Filings File with Annual Premium Tax Report or separately. StateAbbrv: AK. Insurance Type: LAH. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Alaska Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Rebecca Nesheim, Tax Auditor. Contact Email: rebecca.nesheim@alaska.gov. Contact Phone: 907-465-2584. Due by Postmark or Receive Date: Postmark. Filing Method: Hard Copy. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AK - Health Checklist

State Required Filings If the annual statement is not postmarked by March 1, a late fee will be assessed per day. StateAbbrv: AK. Insurance Type: Health. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Alaska Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Rebecca Nesheim, Tax Auditor. Contact Email: rebecca.nesheim@alaska.gov. Contact Phone: 907-465-2584. Due by Postmark or Receive Date: Postmark. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AK - LAH Checklist

State Required Filings If the annual statement is not postmarked by March 1, a late fee will be assessed per day. StateAbbrv: AK. Insurance Type: LAH. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Alaska Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Rebecca Nesheim, Tax Auditor. Contact Email: rebecca.nesheim@alaska.gov. Contact Phone: 907-465-2584. Due by Postmark or Receive Date: Postmark. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AK - Minimum Asset Reserve Report

State Required Filings Domestics Only. StateAbbrv: AK. Insurance Type: Health. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Alaska Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Rebecca Nesheim, Tax Auditor. Contact Email: rebecca.nesheim@alaska.gov. Contact Phone: 907-465-2584. Due by Postmark or Receive Date: Postmark. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AK - PC Checklist

State Required Filings If the annual statement is not postmarked by March 1, a late fee will be assessed per day. StateAbbrv: AK. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Alaska Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Rebecca Nesheim, Tax Auditor. Contact Email: rebecca.nesheim@alaska.gov. Contact Phone: 907-465-2584. Due by Postmark or Receive Date: Postmark. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AK - Signed Jurat

State Required Filings StateAbbrv: AK. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Alaska Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Rebecca Nesheim, Tax Auditor. Contact Email: rebecca.nesheim@alaska.gov. Contact Phone: 907-465-2584. Due by Postmark or Receive Date: Postmark. Filing Method: Hard Copy. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AK - State Filing Fees

State Required Filings StateAbbrv: AK. Insurance Type: Health. LAH. PC. Reinsurance. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Alaska Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Rebecca Nesheim, Tax Auditor. Contact Email: rebecca.nesheim@alaska.gov. Contact Phone: 907-465-2584. Due by Postmark or Receive Date: Postmark. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - Accepted Reinsurers Annual Maintenance Transmittal Form

State Required Filings All Accepted Reinsurers in the State of Alabama must pay the ANNUAL MAINTENANCE FEE. Make checks payable to the: Alabama Department of Insurance Mail form and check to: Postal Service Alabama Department of Insurance c/o Compass Bank PO Box 830707 Birmingham, AL 35283-0707 Courier or Express Service Alabama Department of Insurance c/o Compass Bank 701 South 32nd Street Birmingham, AL 35233. StateAbbrv: AL. Insurance Type: Reinsurance. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - Alabama Business Page

State Required Filings The Alabama business page should be emailed along with premium tax documentation to premiumtax@insurance.alabama.gov. StateAbbrv: AL. Insurance Type: LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Ann Strickland, Examiner. Contact Email: Ann.Strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive Date. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - Application for Renewal of Certificate of Authority

State Required Filings StateAbbrv: AL. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Ann Strickland, Examiner. Contact Email: Ann.Strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive Date. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - Certificate of Compliance

State Required Filings StateAbbrv: AL. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Ann Strickland, Examiner. Contact Email: Ann.Strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive Date. Filing Method: Electronic. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - Certificate of Deposit

State Required Filings StateAbbrv: AL. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Ann Strickland, Examiner. Contact Email: Ann.Strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive Date. Filing Method: Electronic. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - Certificate of Valuation

State Required Filings StateAbbrv: AL. Insurance Type: Health. LAH. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Ann Strickland, Examiner. Contact Email: Ann.Strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive Date. Filing Method: Electronic. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - Health Checklist

State Required Filings StateAbbrv: AL. Insurance Type: Health. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Ann Strickland, Examiner. Contact Email: Ann.Strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive Date. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - LAH Checklist

State Required Filings Mailing address: Alabama Department of Insurance 201 Monroe Street, Suite 1700 Montgomery, AL 36104. StateAbbrv: AL. Insurance Type: LAH. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Ann Strickland, Examiner. Contact Email: Ann.Strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive Date. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - Official List

State Required Filings Mailing Address: Alabama Department of Insurance 201 Monroe Street, Suite 1700 Montgomery, AL 36104 Or P.O. Box 303351 Montgomery, AL 36130-3351. StateAbbrv: AL. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Ann Strickland, Examiner. Contact Email: ann.strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - PC Checklist

State Required Filings Mailing address: Alabama Department of Insurance 201 Monroe Street, Suite 1700 Montgomery, AL 36104. StateAbbrv: AL. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Ann Strickland, Examiner. Contact Email: Ann.Strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive Date. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - Signed Jurat

State Required Filings Since the hard copy annual statement is no longer required to be mailed to the Department but filed electonically with the NAIC, submit signed Jurat page to: Alabama Department of Insurance 201 Monroe Street, Suite 1700 Montgomery, AL 36130-3351. StateAbbrv: AL. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Ann Strickland, Examiner. Contact Email: Ann.Strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive Date. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AL - SL Audit and Exam Transmittal Form

State Required Filings All insurers are required to submit an annual audit and examination fee of $850 accompanied by this form to: POSTAL SERVICE: Alabama Department of Insurance c/o Compass Bank P.O. Box 830707 Birmingham, AL 35283-0707 COURIER OR EXPRESS DELIVERY: Alabama Department of Insurance c/o Compass Bank 701 South 32nd Street Birmingham, AL 35233. State Form ID: PR. StateAbbrv: AL. Insurance Type: Surplus Lines. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Ann Strickland. Contact Email: ann.strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive Date. Filing Method: Hard Copy. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: http://www.eagletm.com/StateMapRedirect/redirect.aspx?LinkType=9&Year=1&StAbbrv=Alabama&InsType=ALs-001_SL_Filing_Requirements.pdf&TableName=ICC. Thursday, March 1, 2012.

AL - State Filing Fees

State Required Filings Annual Statement Filing Fee The Renewal Fee and Filing Fee must be submitted with the Premium Tax Return and mailed by Postal Service to: Alabama Department of Insurance c/o Compass Bank P.O. Box 830691 Birmingham, AL 35283-0691. StateAbbrv: AL. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Alabama Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Ann Strickland, Examiner. Contact Email: Ann.Strickland@insurance.alabama.gov. Contact Phone: 334-241-4154. Due by Postmark or Receive Date: Receive Date. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AR - Advertising Certificate of Compliance

State Required Filings This can be emailed to Kimberly.johnson@arkansas.gov in pdf file format only. StateAbbrv: AR. Insurance Type: Health. LAH. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arkansas Insurance Department. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Kimberly Johnson, Examiner. Contact Email: Kimberly.johnson@arkansas.gov. Contact Phone: 501-371-2680. Due by Postmark or Receive Date: Receive Date. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AR - Annual Continuation Filing Fee - Domestic SL Insurers (Form AID AC SLI-T(D))

State Required Filings Mail to: Arkansas Insurance Department ATTN: Accounting Division 1200 W. 3rd Street Little Rock, AR 72201-1904. State Form ID: AID AC SLI-T(D). StateAbbrv: AR. Insurance Type: Surplus Lines. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arkansas Insurance Department. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Accounting Division. Contact Phone: 501-371-2605. Due by Postmark or Receive Date: Receive Date. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AR - AR Domestic Insurers Affiliated Transaction Form (Form AID FI STDR)

State Required Filings Domestics not subjecct to the Holding Co ACY. The original and one copy of the form should be mailed to: Arkansas Insurance Department Finance Division 1200 West Third Street Little Rock, AR 72201-1904 This form may be filed electronically as a PDF file by emailing to insurance.finance@arkansas.gov. If filed electronically, the original form evidencing the original signatures should be kept on file at the Company for 5 years. State Form ID: AID-FI-STDR. StateAbbrv: AR. Insurance Type: Health. LAH. PC. Surplus Lines. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arkansas Insurance Department. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Kimberly Johnson, Examiner. Contact Email: Kimberly.johnson@arkansas.gov. Contact Phone: 501-371-2680. Due by Postmark or Receive Date: Receive Date. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AR - ARRUA Form

State Required Filings See supporting link information. The ARRUA form collects premium information from companies holding a property license in Arkansas. It must be completed and submitted by March 1, annually. The form is available for online submission between December 15 and March 1. StateAbbrv: AR. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arkansas Insurance Department. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Becky Harrington or Sandy Williams. Contact Email: alexa.grissom@arkansas.gov or sandyw.@amcins.com. Contact Phone: 501-371-2800 or 501-250-7400. Due by Postmark or Receive Date: Receive Date. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AR - Certificate of Deposit

State Required Filings All foreign insurance companies who hold a certificate of authority in Arkansas are required to send under separate cover an original Certificate of Deposit from their state of domicile. Send under separate cover to: Arkansas Insurance Department Attn: Malisa Landers, Securities Administrator 1200 W. Third Street Little Rock, AR 72201-1904. StateAbbrv: AR. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arkansas Insurance Department. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Email: Malisa.landers@arkansas.gov. Contact Phone: 501-371-2679. Due by Postmark or Receive Date: Receive Date. Filing Method: Hard Copy. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AR - Health Checklist

State Required Filings Domestic Only. StateAbbrv: AR. Insurance Type: Health. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arkansas Insurance Department. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Kimberly Johnson, Examiner. Contact Email: Kimberly.johnson@arkansas.gov. Contact Phone: 501-371-2680. Due by Postmark or Receive Date: Receive Date. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AR - LAH Checklist

State Required Filings Domestic Only. StateAbbrv: AR. Insurance Type: LAH. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arkansas Insurance Department. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Kimberly Johnson, Examiner. Contact Email: Kimberly.johnson@arkansas.gov. Contact Phone: 501-371-2680. Due by Postmark or Receive Date: Receive Date. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AR - Mandatory AR Comprehensive Health Insurance Pool Form

State Required Filings All insurers shall complete the attached information form, including those insurers that do not write, or are not licensed to write, accident and health insurance premiums in Arkansas. Mail to: Arkansas Comprehensive Health Insurance Pool PO Box 419 Little Rock, Arkansas 72203 Overnight Delivery Address: Hollie McLain / CHIP c/o Mitchell, Williams,Selig, Gates & Woodyard 425 W. Capitol Avenue, Suite 1800 Little Rock, Arkansas 72201-3525. StateAbbrv: AR. Insurance Type: Health. LAH. PC. Risk Retention Group. Surplus Lines. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arkansas Comprehensive Health Insurance Pool. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Hollie McLain. Contact Email: hmclain@mwlaw.com. Contact Phone: 501-688-8800 OR 501-370-2659. Due by Postmark or Receive Date: Receive Date. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AR - PC Checklist

State Required Filings Domestic Only. StateAbbrv: AR. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arkansas Insurance Department. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Kimberly Johnson, Examiner. Contact Email: Kimberly.johnson@arkansas.gov. Contact Phone: 501-371-2680. Due by Postmark or Receive Date: Receive Date. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AR - Premiums to Mandatory PC Guaranty Fund Information Sheet (Form APCGF-1)

State Required Filings Please attach a copy of your Arkansas Business Page, legal size only. The original signed form should be returned to the following: Arkansas Property & Casualty Guaranty Fund 1023 West Capitol Ave, Suite 2 Little Rock, Arkansas 72201. State Form ID: APCGF-1. StateAbbrv: AR. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arkansas Insurance Department. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Phone: 501-371-2776. Due by Postmark or Receive Date: Receive Date. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AR - RRG Checklist

State Required Filings Domestic only. StateAbbrv: AR. Insurance Type: Risk Retention Group. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arkansas Insurance Department. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Kimberly Johnson, Examiner. Contact Email: Kimberly.johnson@arkansas.gov. Contact Phone: 501-371-2680. Due by Postmark or Receive Date: Receive Date. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AR - Signed Jurat

State Required Filings Foreign companies must file this page for Annual filing only. Document must be filed in electronic .pdf format at: Kimberly.johnson@arkansas.gov. StateAbbrv: AR. Insurance Type: Health. LAH. PC. Risk Retention Group. Surplus Lines. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arkansas Insurance Department. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Kimberly Johnson, Examiner. Contact Email: Kimberly.johnson@arkansas.gov. Contact Phone: 501-371-2680. Due by Postmark or Receive Date: Receive Date. Filing Method: Electronic. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AR - SL Checklist

State Required Filings Domestic Only. StateAbbrv: AR. Insurance Type: Surplus Lines. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arkansas Insurance Department. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Kimberly Johnson, Examiner. Contact Email: Kimberly.johnson@arkansas.gov. Contact Phone: 501-371-2680. Due by Postmark or Receive Date: Receive Date. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - Annual Statement Filings Worksheet - Foreign and Alien Accredited Reinsurers (Form E-AR.AS)

State Required Filings State Form ID: E-AR.AS. StateAbbrv: AZ. Insurance Type: Reinsurance. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arizona Department of Insurance, Insurance Tax Unit - Compliance Section. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Compliance Section. Contact Phone: 602-364-3245. Due by Postmark or Receive Date: Postmark. Filing Method: Electronic. Hard Copy. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - Annual Tax and Fees Report - Health Organization (Form E-HEALTHORG)

State Required Filings Do not mail this form or your payment inside your Annual Statement package. Mail your check with this report separately to Attention: Tax Unit at: Department of Insurance State of Arizona Insurance Tax Unit - Tax Unit 2910 North 44th Street, Suite 210 Phoenix, AZ 85018-7269. State Form ID: E-HEALTHORG. StateAbbrv: AZ. Insurance Type: Health. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Department of Insurance, State of Arizona, Insurance Tax Unit - Tax Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact Phone: 602-364-3997. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - Arizona State Page

State Required Filings StateAbbrv: AZ. Insurance Type: LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arizona Department of Insurance, Insurance Tax Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Tony McCormack. Contact Email: AMccormack@azinsurance.gov. Contact Phone: 602-364-3245. Due by Postmark or Receive Date: Postmark. Filing Method: Hard Copy. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - Arizona State Pages 29 and Supp35 or Supp72

State Required Filings StateAbbrv: AZ. Insurance Type: Health. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arizona Department of Insurance, Insurance Tax Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Tony McCormack. Contact Email: AMccormack@azinsurance.gov. Contact Phone: 602-364-3245. Due by Postmark or Receive Date: Postmark. Filing Method: Hard Copy. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - Captive Annual Report Checklist

State Required Filings Department of Insurance Captive Insurance Division 2910 North 44th Street, Suite 210 Phoenix, Arizona 85018-7269. StateAbbrv: AZ. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arizona Department of Insurance, Captive Insurance Division. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - Certificate of Disclosure (Form E-178)

State Required Filings The form should be directed immediately to your executive officers or directors who are listed on the Jurat Page for notarized original signatures. Incomplete certificates will not be accepted and may result in statutory penalty per day. Mail certificate to: Arizona Department of Insurance Life and Health Division 2910 North 44th Street, Suite 210 Pheonix, AZ 85018-7269. State Form ID: E-178. StateAbbrv: AZ. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arizona Department of Insurance, Insurance Tax Unit - Compliance Section. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Tony McCormack. Contact Email: AMccormack@azinsurance.gov. Contact Phone: 602-364-3245. Due by Postmark or Receive Date: Postmark. Filing Method: Hard Copy. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - Certificate of Disclosure (Form E-178Captives)

State Required Filings An incomplete or late filing of the Certificate of Disclosure will subject an insurer to payment of late fees for each day of delinquency. The late fees are in addition to any other applicable penalty fee or civil penalty. State Form ID: E-178Captive. StateAbbrv: AZ. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arizona Department of Insurance, Captive Insurance Division. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Captive Insurance Division. Contact Phone: 602-364-4490. Filing Method: Hard Copy. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - Health Checklist

State Required Filings Pages 1-4 only of this form with Column 1 and contact information completed. State Form ID: E-NAIC.HEALTH. StateAbbrv: AZ. Insurance Type: Health. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arizona Department of Insurance, Insurance Tax Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Tony McCormack. Contact Email: AMccormack@azinsurance.gov. Contact Phone: 602-364-3245. Due by Postmark or Receive Date: Postmark. Filing Method: Hard Copy. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - HIPAA Data Report and Instructions (Form HIPAA 3-1)

State Required Filings Must be filed if you offer health insurance coverage in the individual market. This form with Exhibits I, II and III must be sent to: Life and Health Division, Arizona Department of Insurance 2910 North 44th Street, Suite 210 Phoenix, AZ 85019-7269. State Form ID: HIPAA 3-1. StateAbbrv: AZ. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arizona Department of Insurance, Life and Health Division. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Life and Health Division. Contact Phone: 602-364-2393. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - HIPAA Report on Earned Premium Volumes and Covered Individuals (Form HIPAA-II)

State Required Filings Must be filed if you offer health insurance coverage in the individual market. This form with Exhibits I, II and III must be sent to: Life and Health Division, Arizona Department of Insurance 2910 North 44th Street, Suite 210 Phoenix, AZ 85018-7269. State Form ID: HIPAA II. StateAbbrv: AZ. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arizona Department of Insurance, Life and Health Division. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Life and Health Division. Contact Phone: 602-364-2393. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - HIPAA Report on Products and Marketing Materials Available to Eligible Individuals (Form HIPAA-III)

State Required Filings Must be filed if you offer health insurance coverage in the individual market. This form with Exhibits I, II and III must be sent to: Life and Health Division, Arizona Department of Insurance 2910 North 44th Street, Suite 210 Phoenix, AZ 85018-7269. State Form ID: HIPAA III. StateAbbrv: AZ. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arizona Department of Insurance, Life and Health Division. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Life and Health Division. Contact Phone: 602-364-2393. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - HIPAA Report on Products Offered in the Individual Marketplace (Form HIPAA-I)

State Required Filings Must be filed if you offer health insurance coverage in the individual market. This form with Exhibits I, II and III must be sent to: Life and Health Division, Arizona Department of Insurance 2910 North 44th Street, Suite 210 Phoenix, AZ 85018-7269. State Form ID: HIPAA I. StateAbbrv: AZ. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arizona Department of Insurance, Life and Health Division. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Life and Health Division. Contact Phone: 602-364-2393. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - LAH Checklist

State Required Filings Pages 1-4 only of this form with Column 1 and contact information completed. State Form ID: E-NAIC.LD. StateAbbrv: AZ. Insurance Type: LAH. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arizona Department of Insurance, Insurance Tax Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Tony McCormack. Contact Email: AMccormack@azinsurance.gov. Contact Phone: 602-364-3245. Due by Postmark or Receive Date: Postmark. Filing Method: Hard Copy. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - Mortgage Guaranty Minimum Policyholders Position (Form E-MG.MPP)

State Required Filings All Mortgage Guaranty Insurers must file a hard copy Quarterly Statement including the Confidential Supplementary Schedule F-5 and Form E-MG.MPP. Foreign mortgage guaranty insurers must file this report with their Form E-NAIC.PC annual filing checklist AND with their hard copy Quarterly Financial Statements. State Form ID: E-MG.MPP. StateAbbrv: AZ. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arizona Department of Insurance, Insurance Tax Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Tony McCormack. Contact Email: AMccormack@azinsurance.gov. Contact Phone: 602-364-3245. Due by Postmark or Receive Date: Postmark. Filing Method: Hard Copy. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - Mortgage Guaranty Supplementary Schedule F-5 (Form E-MG.CEDE)

State Required Filings All Mortgage Guaranty Insurers must file a hard copy Quarterly Statement including the Confidential Supplementary Schedule F-5 and Form E-MG.MPP. Foreign insurers must file this report with their Form E-NAIC.PC annual filing checklist and with their hard copy Quarterly Financial Statements. Label your Supplementary Schedule F-5 report as CONFIDENTIAL and send it to: Arizona Department of Insurance Insurance Tax Unit - Compliance Section 2910 North 44th Street, Sutie 210 Pheonix, AZ 85018-7269. State Form ID: E-MG.CEDE. StateAbbrv: AZ. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arizona Department of Insurance, Insurance Tax Unit - Compliance Section. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Tony McCormack. Contact Email: AMccormack@azinsurance.gov. Contact Phone: 602-364-3245. Due by Postmark or Receive Date: Postmark. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - PC Checklist

State Required Filings Pages 1-4 only of this form with Column 1 and contact information completed. State Form ID: E-NAIC.PC. StateAbbrv: AZ. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arizona Department of Insurance, Insurance Tax Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Tony McCormack. Contact Email: AMccormack@azinsurance.gov. Contact Phone: 602-364-3245. Due by Postmark or Receive Date: Postmark. Filing Method: Hard Copy. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - Report of Policies Issued to Industrial Insureds (Form E-PC.INDINS)

State Required Filings Do not file this report if you did not issue a policy to an industrial insured. State Form ID: E-PC.INDINS. StateAbbrv: AZ. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arizona Department of Insurance, Insurance Tax Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Tony McCormack. Contact Email: AMccormack@azinsurance.gov. Contact Phone: 602-364-3245. Due by Postmark or Receive Date: Postmark. Filing Method: Hard Copy. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - RRG Annual Statement Worksheet - Foreign and Alien (Form E-RRG.AS)

State Required Filings State Form ID: E-RRG.AS. StateAbbrv: AZ. Insurance Type: Risk Retention Group. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arizona Department of Insurance, Insurance Tax Unit - Compliance Section. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Compliance Section. Contact Phone: 602-364-3245. Due by Postmark or Receive Date: Postmark. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - Signed Jurat

State Required Filings Domestic - must have original notarized signatures of two (2) of your executive officers who are listed on your jurat page. StateAbbrv: AZ. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arizona Department of Insurance, Insurance Tax Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Tony McCormack. Contact Email: AMccormack@azinsurance.gov. Contact Phone: 602-364-3245. Due by Postmark or Receive Date: Postmark. Filing Method: Hard Copy. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - State Filing Fees

State Required Filings Annual filing fee amounts vary and are specified in Tax and Fees Report forms. Domestic companies must annually file an Accounts Letter of Qualifications. You may electronically file and pay taxes and fees via NAIC OPTins System. Mail To: Arizona Department of Insurance ATTN: Tax Unit Insurance Tax Unit 2910 North 44th Street, Suite 210 Phoenix, Arizona 85018-7269. StateAbbrv: AZ. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Arizona Department of Insurance, Insurance Tax Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Tony McCormack. Contact Email: AMccormack@azinsurance.gov. Contact Phone: 602-364-3245. Due by Postmark or Receive Date: Postmark. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

AZ - Statement and Tax Payment for the AZ Portion of a Multi State SL Transaction (Form E-159MS)

State Required Filings The tax payment must be payable to the Arizona Department of Insurance and must accompany the report Form E-159MS. Do not send checks and reports separately. Thursday, March 1, 2012.

AZ - Survey of Arizona Domestic Insurers

State Required Filings This survey is required to be filed with your Annual Premium Tax and Fees Report Form. Thursday, March 1, 2012.

CA - Actuarial Statement of Reserve and Pricing Adequacy for Certain Separate Account Guarantees for General Account

State Required Filings StateAbbrv: CA. Insurance Type: Health. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: California Department of Insurance, Financial Analysis Division - Financial Records Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Actuarial Office. Contact Phone: 213-346-6854 or 213-346-6164. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CA - AH Insurers-Reinsurers with WC Exposures - LAH (Form FAD151) - Excel

State Required Filings For insurers and reinsurers with workers' compensation exposures (Licensed for 6). For questions concerning the completion of this form, please contact the Workers' Compensation Deposit Review Team at 213-346-6433. State Form ID: FAD151. StateAbbrv: CA. Insurance Type: Health. LAH. Reinsurance. Workers Compensation. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: California Department of Insurance, Financial Analysis Division - Financial Records Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Financial Records Unit. Contact Phone: 213-346-6423. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CA - AH Insurers-Reinsurers with WC Exposures (Form FAD151) - Excel

State Required Filings For insurers and reinsurers with workers' compensation exposures (Licensed for 6). For questions concerning the completion of this form, please contact the Workers' Compensation Deposit Review Team at 213-346-6433. State Form ID: FAD151. StateAbbrv: CA. Insurance Type: PC. Reinsurance. Workers Compensation. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: California Department of Insurance, Financial Analysis Division - Financial Records Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Financial Records Unit. Contact Phone: 213-346-6423. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CA - Authorization for Disclosure of Financial Records (Form FAD107) - Excel

State Required Filings Please use blue ink for signature(s) required. Hard copy of signature page(s) required. Send original(s) to: California Department of Insurance Financial Analysis Division, Financial Records Unit 300 South Spring Street, 13th Floor Los Angeles, CA 90013. State Form ID: FAD107. StateAbbrv: CA. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: California Department of Insurance, Financial Analysis Division - Financial Records Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Financial Records Unit. Contact Phone: 213-346-6423. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: http://www.eagletm.com/StateMapRedirect/redirect.aspx?LinkType=9&Year=1&StAbbrv=California&InsType=CA-001_Annual_and_Quarterly_Filing_Requirements_and_Instructions_-_PC.cfm&TableName=ICC. Thursday, March 1, 2012.

CA - CA Affidavit - Declaration to Valuation of Property and Securities Verification (Form FAD105) - Excel

State Required Filings Please use blue ink for signature(s) required. Hard copy of signature page(s) required. Send original(s) to: California Department of Insurance Financial Analysis Division, Financial Records Unit 300 South Spring Street, 13th Floor Los Angeles, CA 90013. State Form ID: FAD105. StateAbbrv: CA. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: California Department of Insurance, Financial Analysis Division - Financial Records Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Financial Records Unit. Contact Phone: 213-346-6423. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: http://www.eagletm.com/StateMapRedirect/redirect.aspx?LinkType=9&Year=1&StAbbrv=California&InsType=CA-001_Annual_and_Quarterly_Filing_Requirements_and_Instructions_-_PC.cfm&TableName=ICC. Thursday, March 1, 2012.

CA - Certificate of Compliance

State Required Filings California domestic companies are not required to file a Certificate of Compliance with CDI. Foreign and commercially domiciled companies must file a Certificate of Compliance with CDI from their state of domicile. Submit online using (OASIS) Online Assistance System for Insurer Submittals. California companies that are required to file a Certificate of Compliance with other states should contact the Legal Division to obtain a copy. California Department of Insurance Legal Division Re: Certificate of Compliance 45 Fremont Street, 24th Floor San Francisco, CA 94105 415-538-4154. StateAbbrv: CA. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: California Department of Insurance, Financial Analysis Division - Financial Records Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Financial Records Unit. Contact Phone: 213-346-6423. Filing Method: Hard Copy. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CA - Certificate of Deposit

State Required Filings CICS 1591(a) All of its assets within the United States on deposit with officers of any state thereof for the benefit and security of all policyholders, or of all the policyholders and creditors, of such alien insurer within the United States. Such assets so deposited are designated general state deposits. Applies to admitted alien insurers only. Not to be confused with the workers' compensation deposit. For other questions on deposit, please contact Tax and Securities Unit, Accounting Services Bureau in Sacramento at 916-492-3225. StateAbbrv: CA. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: California Department of Insurance, Financial Analysis Division - Financial Records Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Financial Records Unit. Contact Phone: 213-346-6423. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CA - Health Checklist

State Required Filings With Column 1 completed. State Form ID: FAD103. StateAbbrv: CA. Insurance Type: Health. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: California Department of Insurance, Financial Analysis Division - Financial Records Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Financial Records Unit. Contact Phone: 213-346-6423. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CA - Iran Related Investments - 4th Quarter Data Workbook

State Required Filings Hardcopies, facsimile copies and/or Adobe (pdf) versions of the workbook will not be accepted. Only electronic copies of the data workbook, in Microsoft Exel Format, will be accepted. Please send this workbook via your standard email operating procedures to: CDISupplemental@insurance.ca.gov. StateAbbrv: CA. Insurance Type: Health. LAH. PC. Filing Period: Qtr 4. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: California Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Leo Lara. Contact Email: laral@insurance.ca.gov. Contact Phone: 213-346-6474. Filing Method: Electronic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CA - LAH and Health Trusteed Surplus Statement (Form FAD490) - Excel

State Required Filings For alien companies only. State Form ID: FAD490. StateAbbrv: CA. Insurance Type: Health. LAH. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: California Department of Insurance, Financial Analysis Division - Financial Records Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Financial Records Unit. Contact Phone: 213-346-6423. Filing Method: Hard Copy. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CA - LAH and Health Trusteed Surplus Statement (NAIC) - Excel

State Required Filings For alien companies only. State Form ID: FAD490. StateAbbrv: CA. Insurance Type: Health. LAH. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: California Department of Insurance, Financial Analysis Division - Financial Records Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Financial Records Unit. Contact Phone: 213-346-6423. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CA - LAH Checklist

State Required Filings With Column 1 completed. State Form ID: FAD103. StateAbbrv: CA. Insurance Type: LAH. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: California Department of Insurance, Financial Analysis Division - Financial Records Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Financial Records Unit. Contact Phone: 213-346-6423. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CA - Life Insurer Valuation Certificate

State Required Filings Mail data to: Chief Actuary Department of Insurance 300 South Spring Street, South Tower Los Angeles, CA 90013. StateAbbrv: CA. Insurance Type: Health. LAH. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: California Department of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CA - PC Checklist

State Required Filings With Column 1 completed. State Form ID: FAD103. StateAbbrv: CA. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: California Department of Insurance, Financial Analysis Division - Financial Records Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Financial Records Unit. Contact Phone: 213-346-6423. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CA - PC Trusteed Surplus Statement (Form FAD490) - Excel

State Required Filings For alien companies only. State Form ID: FAD490. StateAbbrv: CA. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: California Department of Insurance, Financial Analysis Division - Financial Records Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Financial Records Unit. Contact Phone: 213-346-6423. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: http://www.eagletm.com/StateMapRedirect/redirect.aspx?LinkType=9&Year=1&StAbbrv=California&InsType=CA-010_Annual_and_Quarterly_Filing_Requirements_and_Instructions_-_LAH.cfm&TableName=ICC. Thursday, March 1, 2012.

CA - PC Trusteed Surplus Statement (NAIC) - Excel

State Required Filings For alien companies only. State Form ID: FAD490. StateAbbrv: CA. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: California Department of Insurance, Financial Analysis Division - Financial Records Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Financial Records Unit. Contact Phone: 213-346-6423. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CA - RRG Checklist

State Required Filings For company reference only. StateAbbrv: CA. Insurance Type: Risk Retention Group. Filing Period: Annual. State Authority: California Department of Insurance, Financial Analysis Division - Financial Records Unit. Contact: Financial Records Unit. Contact Phone: 213-346-6423. Thursday, March 1, 2012.

CA - Schedule-LS (Form FAD135) - Excel

State Required Filings File online using OASIS. Only domestic insurers with securities lending activites during the year are required to complete the schedule. State Form ID: FAD135. StateAbbrv: CA. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: California Department of Insurance, Financial Analysis Division - Financial Records Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Financial Records Unit. Contact Phone: 213-346-6423. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: http://www.eagletm.com/StateMapRedirect/redirect.aspx?LinkType=9&Year=1&StAbbrv=California&InsType=CA-100_Annual_and_Quarterly_Filing_Requirements_and_Instructions_-_Health.cfm&TableName=ICC. Thursday, March 1, 2012.

CA - Special Schedule P (Form FAD152)

State Required Filings For insurers licensed to transact workers' compensation insurance in California or authorized to assume the carve-out portion of workers' compensation business in California. FAD 152 (SCASP) filings must be submitted using the (OASIS) Online Assistance System for Insurer Submittals. For SCASP filings please follow naming standards on the SCASP instruction page. Submit 1 file in Excel, 1 signed file in PDF format and 1 hard copy only with original signature. State Form ID: FAD152. StateAbbrv: CA. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: California Department of Insurance, Financial Analysis Division - Financial Records Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Financial Records Unit. Contact Phone: 213-346-6423. Due by Postmark or Receive Date: Postmark. Filing Method: Electronic. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CA - Subsidiary Report - Information Regarding Subsidiaries (Form FAD134)

State Required Filings One (1) copy of the Annual Statement of each of the non-admitted insurance company(ies) is to be filed with this office on or before March 1. Please clearly identify the name of the admitted carrier on the front cover of each of these non-admitted subsidiaries. State Form ID: FAD134. StateAbbrv: CA. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: California Department of Insurance, Financial Analysis Division - Financial Records Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Financial Analysis Division. Contact Phone: 213-346-6423. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CA - Valuation of All Securities on Deposit with California (Form FADA110)

State Required Filings For insurers licensed to transact workers' compensatino insurance in California or authorized to assume the carve-out portion of workers' compensation business in California. FAD A-110 (A110) filings must be submitted online using OASIS. Mail 1 original hardcopy of the Certification Page with the Company's Name and NAIC No. Mail 1 original hardcopy of the Notarization Page (if applicable) with the Company's Name and NAIC No. Mail to: California Department of Insurance Financial Analysis Division - Financial Records Unit 300 South Spring Street, South Tower, 13th Floor Los Angeles, CA 90013. State Form ID: FAD-A110. StateAbbrv: CA. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: California Department of Insurance, Financial Analysis Division - Financial Records Unit. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Financial Records Unit. Contact Phone: 213-346-6423. Due by Postmark or Receive Date: Postmark. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: http://www.eagletm.com/StateMapRedirect/redirect.aspx?LinkType=9&Year=1&StAbbrv=California&InsType=CA-010_Annual_and_Quarterly_Filing_Requirements_and_Instructions_-_LAH.cfm&TableName=ICC. Thursday, March 1, 2012.

CO - Accredited Reinsurer Annual Fee Form

State Required Filings Please attach check to current Fee Form and mail to: Colorado Division of Insurance Corporate Affairs 1560 Broadway, Suite 850 Denver, CO 80202. StateAbbrv: CO. Insurance Type: Reinsurance. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Colorado Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: . Contact Email: DOI.CorporateAffairs@dora.state.co.us. Contact Phone: 303-894-2371, 303-894-2949. Due by Postmark or Receive Date: Receive Date. Filing Method: Hard Copy. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CO - Colorado Business Only Schedule P

State Required Filings All PC insurers file an additional Colorado Business Only Schedule P with their Annual Statement Filing. This form MUST be filed electronically and submitted in the standard NAIC Schedule P format. Filings must be emailed in electronic PDF format to: doi.financialaffairs@dora.state.co.us The electronic PDF filing must have the Company Name, NAIC number and Type of Document in the subject line. If this is not in the subject line, the email may be deleted. Please send one attachment per email. StateAbbrv: CO. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Colorado Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Scott Lloyd. Contact Email: scott.lloyd@dora.state.co.us. Contact Phone: 303-894-7537. Due by Postmark or Receive Date: Receive Date. Filing Method: Electronic. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CO - Health Checklist

State Required Filings StateAbbrv: CO. Insurance Type: Health. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Colorado Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Scott Lloyd. Contact Email: scott.lloyd@dora.state.co.us. Contact Phone: 303-894-7537. Due by Postmark or Receive Date: Receive Date. Filing Method: Electronic. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CO - HMO Annual Fee Form (Form F)

State Required Filings Make check payable to Colorado Division of Insurance and mail along with this form to: Cash Management Colorado Division of Insurance 1560 Broadway, Suite 850 Denver, CO 80202. State Form ID: Form F. StateAbbrv: CO. Insurance Type: Health. HMO. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Colorado Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Scott Lloyd. Contact Email: scott.lloyd@dora.state.co.us. Contact Phone: 303-894-7537. Due by Postmark or Receive Date: Receive Date. Filing Method: Electronic. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CO - LAH Checklist

State Required Filings StateAbbrv: CO. Insurance Type: LAH. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Colorado Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Scott Lloyd. Contact Email: scott.lloyd@dora.state.co.us. Contact Phone: 303-894-7537. Due by Postmark or Receive Date: Receive Date. Filing Method: Electronic. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CO - Market Analysis Contact Information Update

State Required Filings Every company must designate a Market Conduct Contact with the NAIC, including the email address for any existing contact, and submit this information to the NAIC with the Annual Statement. With this addition to the NAIC website for contacts, the Division of Insurance will no longer be separately collecting a Colorado-specific Market Analysis contact person. Fines and penalties for failure to designate a contact person may apply. StateAbbrv: CO. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Colorado Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Kelly Schultz. Contact Email: kelly.schultz@dora.state.co.us. Contact Phone: 303-894-7481. Due by Postmark or Receive Date: Receive Date. Filing Method: Electronic. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CO - MGA Questionnaire

State Required Filings Filings must be emailed in electronic PDF format to: doi.financialaffairs@dora.state.co.us The electronic PDF filing must have the Company Name, NAIC number and Type of Document in the subject line (Example: ABC Insurance Company - 12345 - Annual statement). If this is not in the subject line, the email may be deleted. Please send one attachment per email. StateAbbrv: CO. Insurance Type: LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Colorado Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Scott Lloyd. Contact Email: scott.lloyd@dora.state.co.us. Contact Phone: 303-894-7537. Due by Postmark or Receive Date: Receive Date. Filing Method: Electronic. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CO - Non-Admitted Reinsurer General Instructions - Alien

State Required Filings Please attach check to current Fee Form and mail to: Colorado Division of Insurance Corporate Affairs 1560 Broadway, Suite 850 Denver, CO 80202. StateAbbrv: CO. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Colorado Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: . Contact Email: DOI.CorporateAffairs@dora.state.co.us. Contact Phone: 303-894-2371, 303-894-2949. Due by Postmark or Receive Date: Receive Date. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CO - Non-Admitted Reinsurer General Instructions - Foreign

State Required Filings Please mail completed forms and documents to: Colorado Division of Insurance Corporate Affairs 1560 Broadway, Suite 850 Denver, CO 80202. StateAbbrv: CO. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Colorado Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: . Contact Email: DOI.CorporateAffairs@dora.state.co.us. Contact Phone: 303-894-2371, 303-894-2949. Due by Postmark or Receive Date: Receive Date. Filing Method: Hard Copy. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CO - PC Checklist

State Required Filings StateAbbrv: CO. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Colorado Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Scott Lloyd. Contact Email: scott.lloyd@dora.state.co.us. Contact Phone: 303-894-7537. Due by Postmark or Receive Date: Receive Date. Filing Method: Electronic. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CO - PC Group Captive Checklist

State Required Filings StateAbbrv: CO. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Colorado Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Raymond Akers. Contact Email: raymond.akers@dora.state.co.us. Contact Phone: 303-894-7836. Due by Postmark or Receive Date: Receive Date. Filing Method: Electronic. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CO - Prepaid Dental Care Plan Organizations Annual Fee Form

State Required Filings Make check payable to Colorado Division of Insurance and mail along with this form to: Colorado Division of Insurance Attn: Cash Management 1560 Broadway, Suite 850 Denver, CO 80202. StateAbbrv: CO. Insurance Type: Health. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Colorado Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Due by Postmark or Receive Date: Receive Date. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CO - Prepaid Dental Plans Worksheet

State Required Filings Complete and attach this worksheet to your annual statement filing. Provide a copy of the access plan used by the Plan. StateAbbrv: CO. Insurance Type: Health. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Colorado Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CO - Pure Captive Checklist

State Required Filings StateAbbrv: CO. Insurance Type: PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Colorado Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Raymond Akers. Contact Email: raymond.akers@dora.state.co.us. Contact Phone: 303-894-7836. Due by Postmark or Receive Date: Receive Date. Filing Method: Electronic. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CO - Regional Home Office Application - Long Form

State Required Filings Currently qualified companies that have submitted short form application the past four years, or that no longer qualify for Regional Home Office status under the SIGNIFICANT/DIRECT criteria must use the long form application. Filings should be directed to: Corporate Affairs Section Colorado Division of Insurance 1560 Broadway, Suite 850 Denver, CO 80202 Please do not include the regional home office filing with your annual statement. StateAbbrv: CO. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Colorado Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Due by Postmark or Receive Date: Receive Date. Filing Method: Electronic. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CO - Regional Home Office Application - Short Form

State Required Filings Currently qualified companies that used a long form application in the most recent five prior years may use a short form application. Filings should be directed to: Corporate Affairs Section Colorado Division of Insurance 1560 Broadway, Suite 850 Denver, CO 80202 Please do not include the regional home office filing with your annual statement. StateAbbrv: CO. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Colorado Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Due by Postmark or Receive Date: Receive Date. Filing Method: Electronic. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CO - Regional Home Office Significant Direct Insurance Operations

State Required Filings Any company may use the Significant Direct Operations Form but companies that fail to meet the Significant Direct Operations qualification standards will not be permitted to subsequently submit a long or short form application. Filings should be directed to: Corporate Affairs Section Colorado Division of Insurance 1560 Broadway, Suite 850 Denver, CO 80202 Please do not include the Regional Home Office filing with your Annual Statement filing. StateAbbrv: CO. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Colorado Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CO - Signed Jurat

State Required Filings Foreign companies must file this page (For Annual filing only). Filings must be emailed in electronic PDF format to: doi.financialaffairs@dora.state.co.us The electronic PDF filing must have the Company Name, NAIC number and Type of Document in the subject line. If this is not in the subject line, the email may be deleted. Please send one attachment per email. StateAbbrv: CO. Insurance Type: LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Colorado Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Scott Lloyd. Contact Email: scott.lloyd@dora.state.co.us. Contact Phone: 303-894-7537. Due by Postmark or Receive Date: Receive Date. Filing Method: Electronic. Domestic/Foreign: Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CO - SL Annual Fee Form

State Required Filings Each company must submit a check, drawn on a US bank, made payable to the Colorado Division of Insurance for the Total Amount Due of the applicable fees as stated on the Fee Form F. The check must be attached to the Non Admitted Insurers Writing Surplus Lines Annual Fee Form F for proper credit. A separate check is to be submitted for each company. Attach check to Fee Form F and mail to: Colorado Division of Insurance Corporate Affairs-Surplus Lines 1560 Broadway, Suite 850 Denver, CO 80202. State Form ID: Form F. StateAbbrv: CO. Insurance Type: Surplus Lines. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Colorado Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: . Contact Email: . Contact Phone: 303-894-2371, 303-894-2949. Due by Postmark or Receive Date: Receive Date. Filing Method: Electronic. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CO - Summary of Anti-Fraud Requirements

State Required Filings The insurance company should file the summary if its anti-fraud plan, on or before March 1 each year, with its annual statement. Filings must be emailed in electronic PDF format to: doi.financialaffairs@dora.state.co.us The electronic PDF filing must have the Company Name, NAIC number and Type of Document in the subject line. If this is not in the subject line, the email may be deleted. Please send one attachment per email. StateAbbrv: CO. Insurance Type: LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Colorado Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Scott Lloyd. Contact Email: scott.lloyd@dora.state.co.us. Contact Phone: 303-894-7537. Due by Postmark or Receive Date: Receive Date. Filing Method: Electronic. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CO - Synopsis of Annual Statement Publications (Form S)

State Required Filings Return this completed form directly to the selected newspaper. StateAbbrv: CO. Insurance Type: LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Colorado Division of Insurance. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Scott Lloyd. Contact Email: scott.lloyd@dora.state.co.us. Contact Phone: 303-894-7537. Due by Postmark or Receive Date: Receive Date. Filing Method: Electronic. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CT - Accident & Health Advertising Certificate of Compliance

State Required Filings Certificates only required for companies reporting accident and health premiums. StateAbbrv: CT. Insurance Type: Health. LAH. PC. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Connecticut Insurance Department. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Financial Analysis & Compliance Division. Contact Email: ctinsdept.financial@ct.gov. Contact Phone: 860-297-3814. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CT - Actuarial Certification required under VACARVM

State Required Filings Actuarial Certification required under Actuarial Guideline XLIII. StateAbbrv: CT. Insurance Type: LAH. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Connecticut Insurance Department. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Financial Analysis & Compliance Division. Contact Email: ctinsdept.financial@ct.gov. Contact Phone: 860-297-3814. Domestic/Foreign: Domestic. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CT - Financial Filing Requirements - All Eligible Surplus Lines Insurers

State Required Filings All companies are required to include a completed Connecticut Form SL-10 as a part of their annual and quarterly filings. All mail, including certified and registered mail, should be sent to the Financial Regulation Division, at the following address: P.O. Box 816 Hartford, CT 06142-0816 Mail sent by private delivery service should be sent directly to our address: 153 Market Street, 7th Floor Hartford, CT 06103. State Form ID: Form SL-10. StateAbbrv: CT. Insurance Type: Surplus Lines. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Connecticut Insurance Department. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Financial Analysis & Compliance Division. Contact Email: ctinsdept.financial@ct.gov. Contact Phone: 860-297-3814. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CT - Health Checklist

State Required Filings A checklist with column 1 completed is required to be submitted with all required hard copy filings. StateAbbrv: CT. Insurance Type: Health. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Connecticut Insurance Department. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Financial Analysis & Compliance Division. Contact Email: ctinsdept.financial@ct.gov. Contact Phone: 860-297-3814. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.

CT - LAH Checklist

State Required Filings A checklist with column 1 completed is required to be submitted with all required hard copy filings. StateAbbrv: CT. Insurance Type: LAH. Filing Period: Annual. Direct Link to State Form: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. State Authority: Connecticut Insurance Department. Direct Link to Filing Website: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Contact: Financial Analysis & Compliance Division. Contact Email: ctinsdept.financial@ct.gov. Contact Phone: 860-297-3814. Filing Method: Hard Copy. Domestic/Foreign: Domestic. Foreign. Direct Link To State Checklist Manager: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Direct Link to Supporting Information: AVAILABLE IN ICC PRO: http://www.byetm.com/content.php?page=icctr. Thursday, March 1, 2012.