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CA Department of Insurance

Health Entities - Notices and Forms

Pursuant to California Code of Regulation ("CCR") 2308.1, the Insurance Commissioner ("Commissioner") designates the Internet-based financial filing system operated by the National Association of Insurance Commissioners ("NAIC") as the filing system to receive and store electronic filings of annual and quarterly financial statements from all admitted insurers.

When filed, solely for purposes of a filing made with the NAIC, a document is considered filed with the Commissioner when the filing is accepted by the NAIC.  Any financial statements, which are not required to be filed with the NAIC or required to be filed with the NAIC that is not accepted for filing by the NAIC, shall be filed directly with the California Department of Insurance ("CDI") via the Online Assistance System for Insurer Submittals ("OASIS").

For documents requiring original signature(s)/certification/notarization, the electronic PDF file must contain the required signature(s)/certification/notarization.  In addition, a paper original of a properly executed Jurat page from the related financial statement filed electronically shall be provided to the Commissioner as confirmation of each electronic filing. For admitted foreign and alien insurers, a paper original of such properly executed Jurat page is not needed, if it is already on file with its domestic regulator.

Financial Filings Instructions:

Health Entities .pdf

Form No.

Description

26

Disclosure of Material Transactions .xls

105

CA Affidavit - Declaration to Valuation of Property & Securities/Verification .xls

107

Authorization for Disclosure of Financial Records .xls

A110

Valuation of All Securities on Deposit with California .xls

151

A & H Insurers/Reinsurers with Workers' Compensation Exposures .xls

152

Special California Schedule P ("SCASP") .xls
 "SCASP" Part VII - Actuarial Certification Q&A's .doc

470

Dislosure of Iran-Related Investments .xls

490

CA Trusteed Surplus Statement .xls

800

Report of Dividend - CA .xls

Bulletin 93-6

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Updated Date: 12/09/14

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