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Financial Statement Pdf Form

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Financial Statement Pdf Form document sample

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									STATE OF CALIFORNIA                                                                                                DEPARTMENT OF INSURANCE
FAD-103 (01/10)


                                                       HOME PROTECTION COMPANY

           COMPANY NAME:                                                                 CA Assign bar Code: H-
           Contact:                                                                      Telephone:
           E-Mail Address:                                                               Fax: ______________________________________
           REQUIRED FILINGS IN THE STATE OF:                      CALIFORNIA             Filings Made During the Year 2010
     (1)      (2)                                (3)                               (4)               (5)           (6)        (7)            (8)

   Check-     Line      REQUIRED FILINGS FOR THE ABOVE STATE                       NEW             CA            FORM       DUE        APPLICABLE
   list        #                                                                  ONLINE        Required         SOURCE     DATE          NOTES
                                                                                ELECTRONIC                          *
                                                                                SUBMISSION      Electronic
                                                                                  FILING          Filing
                                                                               REQUIREMENTS       Formats
                                                                                                 Adobe .PDF
                                                                                                  MS Excel;
                                                                                                  MS Word
                                                                                Domestic &
                                                                                 Foreign         See Item A
                                                                                               for more detail
                            STATE FINANCIAL STATEMENTS
                                                                                                MS-Excel
                                                                                                  and                                     FAD201
               1     Annual Statement (8 ½”x14”)                                    1           Adobe Pdf         State     01-Mar      A, B, C, D, E,
                                                                                                 Hard copy of                               F, H
                                                                                                signature page
                                                                                                   required
                                                                                                MS-Excel
                                                                                                  and                        5/15,        FAD201
               2     Quarterly Financial Statement (8 ½” x 14”)                     1           Adobe Pdf         State      8/15,      A, B, C, D, E,
                                                                                                 Hard copy of                               F, H
                                                                                                                             11/15
                                                                                                signature page
                                                                                                   required
                                                                                                                                          FAD350
               3     Management’s Discussion & Analysis                             1           Adobe Pdf        Company    01-Apr      A,B,C,D,E,F,
                                                                                                                                            G,H,

                     CA Affidavit – Declaration to Valuation of Property &                      Adobe Pdf                                 FAD105
               4                                                                    1            Hard copy of     State     01-Mar       A, B, C, E,
                     Securities/ Verification                                                   signature page                              F, H,
                                                                                                   required

                                                                                                Adobe Pdf                                 FAD107
               5     Authorization for Disclosure of Financial Records              1            Hard copy of     State     01-Mar
                                                                                                                                          A, C, E, H
                                                                                                signature page
                                                                                                   required
               6     State Filing Fees                                             Yes                            State     01-Mar         A, B, H
                                                                                                Adobe Pdf         State
                                                                                                 Hard copy of
               7     Form B (Holding Company Registration Statement)                1           signature page
                                                                                                                            30-Apr       A, B, C, E, I
                                                                                                   required
                                                                                                Adobe Pdf         State     30-Apr       A, B, C, E, I
                                                                                                 Hard copy of
               8     Form C (Summary of Registration Statement)                     1
                                                                                                signature page
                                                                                                   required
                                                                                                                                          FAD103
               9     Filings Checklist (with Column 1 completed)                    1           Adobe Pdf        Company    01-Mar         A, H
              10     California Co. Bar Code Number are Required                   Yes                           Company    01-Mar           A, H



                                                       NOTES AND INSTRUCTIONS




FAD-103                                                                                                           HomeProtectionChecklist-2009
Rev (12/08)                                                                    1
              Mailing and Contact Information        Unless otherwise noted, all filing submissions should be made
                                                     electronically using the (OASIS) Online Assistance System for Insurer
                                                     Submittals (See Appendix A). Do not send document hard copies unless
                                                     specifically instructed to do so. Hard copies will not be accepted as official
                                                     filings.

                                                     Electronic Filing Formats

                                                     All required filings must be submitted electronically in the PDF format. The
                                                     PDF file must include any required signatures and notarization. Some
                                                     documents require both PDF and Excel versions. For document filing
                                                     requiring an Excel version the forms are on our website, already in the Excel
                                                     format; fill in the required information, save, then submit as an Excel file.
                                                     NOTE: the Excel version does not require signatures or notary.

                                                     Required Signature Pages

                                                     For documents requiring original signatures of company officers and/or
                                                     representatives, send one (1) paper copy of the signature page (only) in
     A
                                                     addition to the required electronic submission. Mail paper copy of the
                                                     signature page(s) to:

                                                                        California Department of Insurance
                                                          Financial Analysis Division, Financial Records –Home Protection
                                                                  300 South Spring Street, South Tower, 13th Floor
                                                                              Los Angeles, CA 90013

                                                     State filing fees should be mailed directly to Sacramento at:

                                                                          California Department of Insurance
                                                                             Accounting Services Bureau
                                                                             300 Capitol Mall, 14th Floor
                                                                             Sacramento, CA 95814

                                                     For questions and concerns, please contact Financial Records Unit at
                                                     (213)346-6423 or visit CDI website address:http://www.insurance.ca.gov

              Late Filings                           All filings must be submitted before 12:00 midnight of the required due
                                                     date. A required filing may be subject to a late assessment fee if
                                                     submitted after the required due date. A late fee will be assessed for
                                                     the first month and for each month and every month or fractional
                                                     part thereof until submitted.
     B
                                                     Letters requesting an extension to file will be acknowledged as received.
                                                     However, you may still be subject to a late file fee pursuant to California
                                                     Insurance Code (CICS) 924. Upon submission you may be required to
                                                     pay the late filing fees through the (OASIS) Online Assistance System
                                                     for Insurer Submittals when a document is filed late.

              Original Signatures                    Documents containing Original signatures, the signature page(s)
              Signature/Notarization/Certification   must be submitted to the Department for verification, example such as
                                                     the (California Affidavit) for ALL filings from Domestic companies.
                                                     For Foreign and Alien companies only signature page(s) for California
                                                     (State) required documents must be submitted. Facsimile signatures or
                                                     copies of signed Jurat Pages are NOT acceptable and will result in the
                                                     Annual Statement not being accepted as a complete filing.
                                                     California Insurance Code Section (“CICS”) 903 (Verification of statements)
                                                     and 903.5 (Affidavit of Officers) apply.
     C                                               Please use BLUE INK for signatures. (original signatures required)
                                                     Note: As of January 1, 2008, all documents notarized in the state of
                                                     California must comply with Assembly Bill 886 (Chapter 399, Statutes of
                                                     2007) which amends section 8202 of the Government Code and section
                                                     1185 of the Civil Code in reference to establishing an affiants identity
                                                     when executing a Jurat. The amendment no longer allows the identity
                                                     of an affiant to be established by personal knowledge alone. The new
                                                     Jurat form and/or Acknowledge form must be used or the filing will not
                                                     be accepted as a complete filing.
              Amended Filings                        Amended items must be filed within 10 days of their amendment. Please
                                                     submit to the Department an explanation of the amendments. Amended
     D                                               filings requiring original signatures (1) copy must be re- submitted to the
                                                     department for verification.




FAD-103                                                                                          HomeProtectionChecklist-2009
Rev (12/08)                                                  2
               Form Source                                             The checklist column titled “(6) Form Source” identifies where the forms can
                                                                       be acquired.
                                                                       If Column 6 contains “NAIC”, the company must obtain the forms from the
                                                                       appropriate vendor. If the column contains “State of Domicile”, the state of
                                                                       domicile will provide the forms. If this column contains “Company”, the
                                                                       company or its representative (e.g., its CPA firm), is expected to provide the
                                                                       form based upon the appropriate state instructions or the NAIC Annual
                                                                       Statement Instructions. If other than Company, State of Domicile or NAIC is
                                                                       listed as the form source in Column 6, you should check to see if the form is
                                                                       included in the financial filings, form and notices, section of the
                                                                       Department’s website. If the form is not listed there, you may contact the
   E                                                                   appropriate area within the Department, as identified in Column 6, with any
                                                                       questions or requests. Following is a list of contact information:
                                                                       Rate Specialist Bureau: Los Angeles, 14th Floor (213) 346-6774 or 6556
                                                                       Premium Tax Audit Bureau: Los Angeles, 14th Floor (213) 346-6097 or
                                                                       6012
                                                                       Financial Records Unit (“State”): Los Angeles, 13th Floor (213) 346-6423.
                                                                       When contacting the Financial Records Unit to inquire about a State form,
                                                                       please reference the State form number which can be found in Column 8
                                                                       Applicable Notes.
               NONE Filings                                            See NAIC Annual Statement Instructions for Supplemental Interrogatories.
                                                                       Exceptions to these instructions are noted on the form.
     F                                                                 When there is nothing to report, the word “NONE” must appear stamped
                                                                       /written on the form. Company information must be filled in (Company name
                                                                       and NAIC #).
               Management’s Discussion & Analysis                      Reference the instruction of the Management Discussion & Analysis can be
       G                                                               found at our CDI website.
               Bar Codes (State)                                       Please follow the instructions in the California Annual Statement Instructions
       H                                                               letter.
                                                                       Purchase of bar code software is the responsibility of the company.
               Holding Company Act                                     Pursuant to CIC Section 1215.4(a), all domestic and commercially domiciled
                                                                       insurers that are members of a holding company system must register with
                                                                       the Commissioner. The annual holding company registration statements
     I
                                                                       required by CIC Section 1215.4, and commonly referred to as Forms B and
                                                                       C should be submitted on the appropriate forms along with an acceptable
                                                                       form of verification.
 FAD-103                                                                                                                       Homecklist-2009


                                                                General Instructions
                                                           For Companies to Use Checklist

Please Note:         The California Department of Insurance instructions for companies to file with the NAIC are included in this
                     Checklist. The NAIC will send mailing labels and other information to all companies but will not be sending their own
                     checklist this year.

                     Electronic filing is intended to include filing via the Internet or filing via diskette with the NAIC. Companies that file
                     with the NAIC via the Internet are not required to submit diskettes to the NAIC. Companies are not required to file
                     hard copy filings with the NAIC.



              Column (1)      (Checklist)
                              Companies may use the checklist to submit to a state, if the state requests it. Companies should copy the checklist
                              and place an “x” in this column when mailing information to the state.
              Column (2)      (Line #)
                              Line # refers to a standard filing number used for easy reference. This line number may change from year to year.
              Column (3)      (Required Filings) Name of item or form to be filed.
              PLEASE NOTE:             The Annual Statement Electronic Filing includes the annual statement data and all supplements due
                                       March 1, per the Annual Statement Instructions. This includes all detail investment schedules and other
                                       supplements for which the Annual Statement Instructions exempt printed detail.
                                       The March .PDF Filing is the .pdf file for annual statement data, detail for investment schedules, Officers
                                       and Directors Information and supplements due March 1.
                                       The Supplemental Electronic Filing includes all supplements due April 1, per the Annual Statement
                                       Instructions.
                                       The Supplemental .PDF Filing is the .pdf file for all supplemental schedules and exhibits due April 1.
                                       The Quarterly Statement Electronic Filing includes the complete quarterly statement data.
                                       The Quarterly Statement .PDF Filing is the .pdf file for quarterly statement data.
                                       The June .PDF Filing is the .pdf file for the Audited Financial Statements.
              Column (4)      (Filing Requirement)
                              Indicates if the foreign or domestic company is required to file for each type of form. See Notes Section A and
                              Appendix A for detailed submission instructions. The Blanks (E) Task Force modified the 1999 Annual Statement
                              Instructions to waive paper filings of certain NAIC supplements and certain investment schedule detail, if such
                              investment schedule data is available to the states via the NAIC database. The checklists reflect this action taken by
                              the Blanks (EX4) Task Force.

              Column (5)      (Electronic Filing Format)


FAD-103                                                                                                           HomeProtectionChecklist-2009
Rev (12/08)                                                                    3
                               Indicates the electronic filing format(s) required (Adobe PDF, MS Excel, and MS Word). If multiple formats are
                               listed then the document must be filed in each format.

              Column (6)       (Form Source)
                               See Notes and Instructions Section - E for details.
              Column (7)       (Due Date)
                               Indicates the date on which the company must file the form.

              Column (8)       (Applicable Notes)
                               This column contains references to the Notes and Instructions that apply to each item listed on the checklist. The
                               company should carefully read these notes before submitting a filing.

                                                                              APPENDIX A

                                        INSTRUCTIONS FOR CALIFORNIA ONLINE ELECTRONIC FILING REQUIREMENT
                                                        (OASIS) Online Assistance System for Insurer Submittal

                     New for 2010 ALL companies are required to submit all filings electronically using the (OASIS) Online Assistance System
                     for Insurers Submittal. Hard copy filings will not be accepted.

                     Adobe PDF

                     All required filings must be submitted electronically in the PDF format. The PDF file must include any required signatures
                     and notarization.

                     MS Excel

                     Some documents require both PDF and Excel versions. For document filing requiring an Excel version, those forms are on
                     our website already in the Excel format; fill in the required information, save, then submit as an Excel file. NOTE: the Excel
                     version does not require signatures or notary.
                     All of the documents to be filed electronically with the California Department of Insurance should be named as indicated
                     below–

                        File Naming Standard
                     The filename of the document consists of the ca assign bar code number (5 digits), the year (4 digits), the file type (1
                     character) the statement type (2 characters), CA (2 characters), the filing type (1 character), the submission type (1 character),
                     the state form number (6 characters), the file version (1 digit) and the file extension (3 characters).
                     The year is represented by the 4 digits of the filing year. For the 2009 annual statement due March 1, 2010, the year
                     would be 2009.
                     The file type represents the first letter of the business type code of the insurance company. Example: H for Home Protection.
                     The statement type represents the kind of document being filed. Example: AN for annual statement, Q1 = 1st Quarterly.
                     The filing type represents whether the document is an original filing or an amendment. O=original; A= amendment
                     The submission type represents the month the document is required to be submitted. M=March or May, A=April or August,
                     N=November.
                     The state form number represents the document number and can be found under Column 8 Applicable Notes.
                     The file version refers to whether the document is 0 for original filing, 1= 1st amendment, 2= 2nd amendment, etc.
                     for the amended filings.
                     The file extension represents the appropriate filing extension depending on program used. Ex: pdf, xls or doc.


                 Field #                  Field Name                                             Example
                    1       NAIC number/CA barcode number (5 digits)                 H3416
                    2       Year (4 digits)                                          2009
                    3       File type (1 character)                              H = Home Protection
                                                                                 AN = annual, Q1 = 1st Quarterly, Q2 = 2nd Quarterly,
                    4       Statement type (2 characters)
                                                                                 Q3 = 3rd Quarterly
                    5       CA (2 characters)
                    6       Filing type (1 character)                                O = Original or A = Amendment
                                                                                  M = March or May; A = April, August; N =
                    7       Submission Type (1 character)
                                                                                 November
                    8       State form number (6 characters)                         FAD201, FAD350
                    9       File version (1 digit)                                   0 = Original, 1 = 1stAmendment, 2 = 2ndAmendment
                   10       File extension (3 characters)                            pdf, xls, doc
                     There are 23 characters for the filename and 3 characters for file extension with a period in-between field.
                     Examples: H3416.2009.H.AN.CA.O.M.FAD2010.pdf
                               H3416.2009.H.Q3.CA.A.M.FAD2012.xls (for 2ndAmendment filing)


FAD-103                                                                                                           HomeProtectionChecklist-2009
Rev (12/08)                                                                     4

								
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