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									                                                                          North Carolina Department of Insurance
                                                                             Life and Health Division Checklist
COMPANY NAME:                                                                                                                                                       Rev. 12/10/09

NAIC Code (#####) :

LEAD FORM #:


    REVIEW
 REQUIREMENTS            REFERENCE                                             COMMENTS                                                             REFERENCE

                                                                                                                                              Please specify location
                                                                                                                                   (Form/Page/Paragraph/Other) of complying
                                                                                                                                   provision/language or attach explanation for
                                                                                                                                                 an N/A response
TYPE of FILING: INDIVIDUAL           WHOLE LIFE OR UNIVERSAL LIFE
                             ITEMS IN BLUE ARE RECENTLY AMENDED/ADDED OR RELATED TO NEW LEGISLATION
                                       On the cover page, first, or insert page of the policy, there shall be a statement that
                                       the policy is a legal contract between the policy owner and the insurer and printed in
Cautionary Notice     NCGS 58-38-20(a)
                                       larger or other contrasting type or color, "Read Your Policy Carefully". Also, an
                                       index of major policy provisions must be provided.

                                           A minimum ten day free look provision is required during which the policy may be
Free Look             T11 NCAC 12.0447
                                           returned for a full refund of all premium paid.
                                           Per NCGS 58-58-22(1), an individual life insurance policy must have a Grace Period
Grace Period          NCGS 58-58-22(1)
                                           provision of a minimum of 31 days.

Contestability                             Per NCGS 58-58-22(2), an individual life policy shall not be contested after it has
                      NCGS 58-58-22(2)
Provision                                  been in force for a period of two (2) years except for non-payment of premium.

                                       Per NCGS 58-58-22(4), an individual life insurance policy may not limit payment of
                                       benefits for Suicide for more than two years after the date of the policy and must
Suicide Exclusion     NCGS 58-58-22(4)
                                       provide for at least a return of premiums paid if the death of the insured is a result of
                                       suicide during the two year period following policy issue.

Misstatement of Age                  Per NCGS 58-58-22(3), an individual life insurance policy must have a provision that
                    NCGS 58-58-22(3)
or Sex                               provides for an equitable adjustment in the event of misstatement of age or gender.

                                           Pursuant to NCGS 58-58-22(5), for individual life policies, the minimum
Reinstatement         NCGS 58-58-22(5)
                                           reinstatement time period after premium default is five (5) years.

                      NCGS 58-58-          Provide an explanation of how compliance with NCGS 58-58-345(e)(5)b. is achieved
Military Sales
                      345(e)(5)b.          when the product is marketed to known service members.




                                                                                            Page 1
                                                                       North Carolina Department of Insurance
                                                                          Life and Health Division Checklist

    REVIEW
 REQUIREMENTS          REFERENCE                                            COMMENTS                                                             REFERENCE

                                                                                                                                           Please specify location
                                                                                                                                (Form/Page/Paragraph/Other) of complying
                                                                                                                                provision/language or attach explanation for
                                                                                                                                              an N/A response
TYPE of FILING: INDIVIDUAL         WHOLE LIFE OR UNIVERSAL LIFE
                                        An insurer may not exclude death by an act of war, declared or undeclared, or death
                                        due to any act related to military service in a policy, certificate, or rider of life
                                        insurance or annuity contract if the insured was a known service member at the time
Military Sales - War NCGS 58-58-
                                        of the sale. A statement similar to the following must be added to the exclusion:
Exclusion            345(f)(5)
                                        This exclusion does not apply when the insured is a known service member and
                                        such was known at the time of sale. Note the exclusion may apply to the accidental
                                        death benefit, if any.


                                    Pursuant to T11 NCAC 4.0314(4) and G.S. 58-58-1, the policy shall either include a
                 T11 NCAC           statement relating to the right of the insured to receive a refund of unearned
Unearned Premium
                 4.0314(4) and G.S. premium (including how the refund shall be made and under what conditions) or a
Refund
                 58-58-1            statement relating that all premiums are considered earned upon payment of the
                                    death benefit.


                                     Pursuant to T 11 NCAC 12.0449 and 12.0416, Graded Death Benefit policies MUST
                                     be sold on a Guaranteed Issue basis. (NOTE: as per the requirements of T11
Graded Death
                    T11 NCAC 12.0449 NCAC 12.0449 applications to be used in guaranteed issue cases shall not have
Benefit and
                    & 12.0416        questions or statements related to the applicants health or health history.) Also, the
Guaranteed Issue
                                     phrase “Graded Death Benefit” MUST appear on the face page of the policy in
                                     BOLD type.

                                        Universal Life Policies shall contain a cautionary statement either on the cover
Cautionary Notice   NCGS 58-58-1        page or within the policy data page that "Coverage may expire prior to the
                                        maturity date if sufficient premiums are not paid".

                    NCGS 58-61-10(a)
Policy Loans                         Policy loan interest rates cannot exceed the fixed or variable rate.
                    & (b)




                                                                                        Page 2
                                                                        North Carolina Department of Insurance
                                                                           Life and Health Division Checklist

    REVIEW
 REQUIREMENTS           REFERENCE                                            COMMENTS                                                              REFERENCE

                                                                                                                                             Please specify location
                                                                                                                                  (Form/Page/Paragraph/Other) of complying
                                                                                                                                  provision/language or attach explanation for
                                                                                                                                                an N/A response
TYPE of FILING: INDIVIDUAL           WHOLE LIFE OR UNIVERSAL LIFE
                                      For agent solicited coverage compliance with T11 NCAC 12.0607(3) requires a
                                      statement, obtained with each application for agent solicited life insurance or
                                      annuity, with or as part of the application, signed by both the applicant and the
                                      agent, as to whether the applicant has existing life insurance policies or annuity
                                      contracts. Compliance may be achieved by revising an application to include a
Replacement -                         question for the applicant (for example: Do you have existing life insurance policies
Agent Solicited      T11 NCAC 12.0607 or annuity contracts?) and another question for the agent (for example: Does the
Coverage                              applicant have existing life insurance policies or annuity contracts?) Please note if
                                      the answer to this question is "yes", the applicant must be provided with the
                                      pertinent replacement notice in the format specified by T11 NCAC 12.0611, whether
                                      or not any intent to replace coverage is indicated. Copies of the replacement notices
                                      may be viewed at the following web address:
                                      http://www.ncdoi.com/LH/Documents/Checklists/AppendixABC.pdf
                                      For direct response solicited coverage compliance with T11 NCAC 12.0608 requires
                                      a statement, obtained with each application for direct response solicited life
                                      insurance or annuity, with or as part of the application, signed by the applicant, as to
Replacement -                         whether the applicant, by applying for the proposed policy or contract, intends to
Direct Response      T11 NCAC 12.0608 replace, discontinue, or change an existing policy or contract. Based upon the
Solicited Coverage                    information so obtained, the applicant must be provided with the pertinent
                                      replacement notice in a format specified by T11 NCAC 12.0611. Copies of the
                                      replacement notice can be found at the following web address:
                                      http://www.ncdoi.com/LH/Documents/Checklists/AppendixABC.pdf

                                    The Replacement Notice that the Department will consider acceptable for use will
                                    be one that the most current format as adopted by the NAIC life Insurance and
                                    Annuities Replacement Model Regulation. Any deviation from this format will be
Replacement Notice T11 NCAC 12.0611
                                    considered NOT to be in compliance with T11 NCAC 12.0611. Copies of the
                                    replacement notice can be found at the following web address:
                                    http://www.ncdoi.com/LH/Documents/Checklists/AppendixABC.pdf

                                         If the policy will be issued as replacement coverage, the free look period for the new
Free Look For
                     T11 NCAC            policy must be a minimum of 30 days. This language may appear on the cover
Replacement
                     12.0612(a)(4)       page of the policy or explanation of how compliance will be achieved must be
Coverage
                                         included within the supporting documents of the filing.




                                                                                         Page 3
                                                                         North Carolina Department of Insurance
                                                                            Life and Health Division Checklist

    REVIEW
 REQUIREMENTS          REFERENCE                                             COMMENTS                                                             REFERENCE

                                                                                                                                            Please specify location
                                                                                                                                 (Form/Page/Paragraph/Other) of complying
                                                                                                                                 provision/language or attach explanation for
                                                                                                                                               an N/A response
TYPE of FILING: INDIVIDUAL            WHOLE LIFE OR UNIVERSAL LIFE
                                         No exclusions related to acts of terrorism allowed. Due to the fact that the Travel
                                         Warnings, Public Announcements and Consular Information Sheets issued by the
                                         State Department may include cautions related to terrorism, terrorist threats, or
Acts of Terrorism &
                    Bulletin 02-B-2      anniversaries of terrorist specific events, riders or policies that exclude or limit
Travel Exclusions
                                         benefits based on information provided by these sources may not be issued in North
                                         Carolina because of the limitations imposed by Bulletin 02-B-2 as it pertains to
                                         exclusions related to Acts of Terrorism.

                                                                                                                                 Please check off to confirm compliance or
GENERAL INFORMATION RE: INDIVIDUAL WHOLE LIFE OR UNIVERSAL LIFE
                                                                                                                                   provide explanation for N/A response.

                    T11 NCAC             All forms must be identified by a form number in the lower left-hand corner of the
Form Numbers
                    12.0329(3)(d)        page.

                                         Form filings or amendments that are subject to the NAIC Guideline XXX, must
                                         contain an actuary’s certification of compliance with T11 NCAC 11F.0400, as
                                         amended OR of compliance with the Valuation of Life Insurance Policies Model
                    T11 NCAC             Regulation as adopted by the NAIC in March 1999. If a form is exempt from
XXX Certification
                    11F.0400             compliance, please provide actuarial certification of this fact, including a specific
                                         citation from the regulation. If the policy form filed is exempt from compliance
                                         with T11 NCAC 11F.0400, actuarial certification of compliance with NCGS 58-
                                         58-50 is required.
Reserve
                    NCGS 58-58-50 &      An actuarial certification of compliance with NCGS 58-58-50 (if exempt from XXX
Requirements &
                    58-58-55             compliance) and 58-58-55 is required.
Nonforfeiture




                                                                                          Page 4
                                                                      North Carolina Department of Insurance
                                                                         Life and Health Division Checklist

    REVIEW
 REQUIREMENTS          REFERENCE                                           COMMENTS                                                               REFERENCE

                                                                                                                                            Please specify location
                                                                                                                                 (Form/Page/Paragraph/Other) of complying
                                                                                                                                 provision/language or attach explanation for
                                                                                                                                               an N/A response
TYPE of FILING: INDIVIDUAL          WHOLE LIFE OR UNIVERSAL LIFE
                                       If the company intends to issue policies based on an sex neutral underwriting
                                       criteria, actuarial certification that the valuation requirements of the State of North
                                       Carolina applicable to life and health insurance companies as stated in NCGS 58-58-
                                       50 and 11 NCAC 11F.0605 must be provided. The certification shall also contain a
                                       statement that the aggregate reserves held by the company on a gender-blended
                                       basis are greater than or equal to the minimum aggregate reserves required by the
Gender Blended      T11 NCAC           State of North Carolina for such policies. The statement shall at least contain a
Reserves            11F.0605           statement similar to the following: " I [name], am [title] of [insurance company name]
                                       and a member of the American Academy of Actuaries. I am familiar with the
                                       valuation requirements of the State of North Carolina applicable to life and health
                                       insurance companies as stated in NCGS. 58-58-50 and 11 NCAC 11F.0605. In my
                                       opinion, the aggregate reserves held by the company on a gender-blended basis
                                       are greater than or equal to the minimum aggregate reserves required by the State
                                       of North Carolina for such policies."

                                       Rates and an actuarial memorandum shall be provided for each form (base
                    T11 NCAC
Rates & Actuarial                      policy or rider) requiring a premium or cost of insurance. An actuarial
                    12.0329(3)(c)
                                       memorandum is also required.
                                       Use of the 2001 CSO Mortality Table for the minimum standard for reserves
                                       and cash values became mandatory effective January 1, 2009. This applies to
                                       all policies subject to NCGS 58-58-50(c)(2)a., NCGS 58-58-55(e)(4)h.6, 11 NCAC
2001 CSO Mortality T11 NCAC
                                       11F.0403(a) or 11NCAC 11F.0403(b). In order for an actuarial memorandum to
Tables             11F.0602
                                       demonstrate compliance, the actuarial memorandum must include statements
                                       that clearly indicate that the 2001 CSO Mortality Table is being used for both
                                       cash values and reserves.

                    NCGS 58-38-        A certified Flesch Scale readability analysis and test score must be provided in
Flesch Score
                    30(b)(1)           accordance with NCGS 58-38-30. A minimum Flesch score of 50 is required.

                                       Per T11 NCAC 04.0503(a), please confirm whether the submitted life forms will be
                                       marketed with or without an illustration that includes non-guaranteed elements. If
                    T11 NCAC           yes, per T11 NCAC 04.0509(d)(2), please submit evidence of compliance with North
Illustration
                    4.0503(a)          Carolina rules governing life insurance illustrations as stipulated under T11 NCAC
                                       04.509(b). If you certify illustration use, please provide a specimen copy of the
                                       actual illustration form.




                                                                                       Page 5
                                                                             North Carolina Department of Insurance
                                                                                Life and Health Division Checklist

    REVIEW
 REQUIREMENTS            REFERENCE                                                COMMENTS                                                              REFERENCE

                                                                                                                                                  Please specify location
                                                                                                                                       (Form/Page/Paragraph/Other) of complying
                                                                                                                                       provision/language or attach explanation for
                                                                                                                                                     an N/A response
TYPE of FILING: INDIVIDUAL            WHOLE LIFE OR UNIVERSAL LIFE
                                             Use of an application is required. Except in the case of direct response sales or
Use of Application is T11 NCAC               group sales, all applications must be signed by a North Carolina licensed agent.
Required              12.0326(a)             Direct response sales are considered to be any sale of life insurance or annuity
                                             where the insurer does not utilize an agent in the sale or delivery of the policy.


                                             Sets forth standards to protect service members of the Armed Forces from
Dishonest and         Part 6 of Article 58
                                             dishonest and predatory insurance sales practices by declaring certain identified
Predatory Sales to    (NCGS 58-58-320
                                             practices to be false, misleading, deceptive or unfair; and requiring disclosure at the
Military Personnel    through 350)
                                             time of sales.


                                             An insurer may not exclude death by an act of war, declared or undeclared, or death
                                             due to any act related to military service in a policy, certificate, or rider of life
Military Sales -                             insurance or annuity contract if the insured was a known service member at the time
                      NCGS 58-58-
Identifying service                          of the sale. A statement similar to the following must be added to the exclusion:
                      345(f)(5)
members                                      This exclusion does not apply when the insured is a known service member and
                                             such was known at the time of sale. Note the exclusion may apply to the accidental
                                             death benefit, if any.


                                        When the product has a side account/fund, submit a certification by an officer of the
Military Sales - Side
                      NCGS 58-58-345(f) company that the requirements of NCGS 58-58-345(f)(1) through (3) will be met
Accounts
                                        when the product is sold to a known service member.


Release of                                   As adopted in Section 23 of HB 1166 effective October 1, 2010, an insurer shall
Information at                               provide the information outlined in NCGS 58-58-97(a)(1) through (5) to an
Request of Funeral NCGS 58-58-97             employees of a funeral establishment when presented with a copy of the a
Establishment                                notification of a death and written authorization. The insurer shall provide the
Employee                                     information as soon possible after receipt of the request.


                                       Pursuant to amendments to G.S. 58-56-26(c) as adopted in House Bill 1183, as
                                       of July 1, 2010, all insurers who contract with third party administrators, as
TPA Use               NCGS 58-56-26(c)
                                       defined in G.S. 58-56-2(5) shall annually file with the Department a certification
                                       of completion of the audits required by G.S. 58-56-26(c).



                                                                                              Page 6
                                                                           North Carolina Department of Insurance
                                                                              Life and Health Division Checklist

    REVIEW
 REQUIREMENTS      REFERENCE                                                     COMMENTS                                                                           REFERENCE

                                                                                                                                                              Please specify location
                                                                                                                                                   (Form/Page/Paragraph/Other) of complying
                                                                                                                                                   provision/language or attach explanation for
                                                                                                                                                                 an N/A response
TYPE of FILING: INDIVIDUAL      WHOLE LIFE OR UNIVERSAL LIFE
                                   A red-line comparison shall be provided with the initial submission of a form that is a
Red-line        T11 NCAC           revision of a previously approved form. The submission shall include a signed
Comparison      12.0329(3)(g)      statement by an Officer of the Company certifying that no other changes, other than
                                   those red-lined, were made to the form(s).

                                   The premium tax rate in North Carolina is 1.9%, unless otherwise specifically
Premium Tax     NCGS 105-228.5
                                   authorized in NCGS 105-228.5.

                                    A detailed reason or explanation as to why a requirement is not
                                   applicable must be provided on a separate page for those
                                   requirements referenced by N/A

                                   I, the filer, acknowledge that I have prepared the submitted form(s) in
                                   accordance with the checklist and to the best of my knowledge this file
                                   is in substantial compliance with all of the above listed reference
                                   points.



                                   Signature of Filer                                                                                              Date

                                   The Life and Health Division checklist is intended to expedite the Departments overall review time of new
                                   form filings. The checklist serves as a basic guide to assist the Industry in preparation of new form filings
                                   prior to submission. The checklist is not a substitute for Departmental review. All forms must comply with
                                   State Insurance Law.




                                                                                                 Page 7

								
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