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INSURERS: Property and Casualty - Notices and Forms 2011 Annual/2012 Quarterly

Annual/Quarterly Statement Financial Filing

The following sections contain Filing Instructions and California specific forms for you to view and download. All required documents must be submitted electronically in PDF, MS-Excel and/or MS-Word formats, utilizing the OASIS (Online Assistance System for Insurer Submittal). Additionally, please submit the original signature pages by the reporting deadline.

Mail to:

California Department of Insurance
Financial Analysis Division
300 South Spring Street, South Tower, 13th Floor
Los Angeles, CA 90013
Attention: Financial Records Unit

Questions or Inquiries contact:
Financial Records
Phone: (213) 346-6423
E-mail: Financial_Records@insurance.ca.gov

Note: Please adjust your left and right margins to zero (0) before selecting the Print button in order to see all text.

All filings must be submitted online before 12:00 midnight of the required due date. A required filing maybe subject to a late assessment fee, if submitted after the required filing date.

View Annual/Quarterly Statement Notices

Form No.	Description	Due Date	Printing and Special Instructions
	List of Insurers or Reinsurers Authorized to Reinsure the Injury, Disablement, or Death Portions of Workers' Compensation Policies
	Annual Statement and Others Requirements Checklist		Print Format: Legal size; Orientation: Portrait
26	Notice and Disclosure of Material Transactions(xls - 54 kb)	When applicable	Print Format: Letter size; Orientation: Portrait
105	CA Affidavit - Declaration to Valuation of Property & Securities/Verification (xls - 721 kb)	03-01-2012	Print Format: Legal size; Orientation: Portrait
107	Authorization for Disclosure of Financial Records (xls - 727 kb)	03-01-2012	Print Format: Letter size; Orientation: Portrait
A-110	Valuation of All Securities on Deposit with California MS-Excel (683-kb)	03-01-2012 05-15-2012 submit an electronic file in both Pdf and Excel formats & the original of signature pages.	Print Format: Legal size; Orientation: Landscape (Except Certification page: Portrait) For insurers licensed to transact workers' compensation insurance in California or authorized to reinsure the injury, disablement, or death portions of policies of workers' compensation insurance under the class of disability insurance.
135	Schedule-LS (4 pages) - For California domiciled companies (xls - 1.42 Mb)	03-01-2012	Print Format: Select Entire workbook, Legal size; Orientation: Page 1: Portrait; Pages 2-3: Landscape
141	California Special Interrogatory (xls - 781 kb)	04-01-2012	Print Format: Select Entire Workbook, Legal size; Orientation: Page 1&3-4: Portrait; Pages 2: Landscape
151	A & H Insurers/Reinsurers with Workers Compensation Exposures (xls - 1.19 Mb)	Upon request	Print Format: Select Entire workbook, Legal size; Orientation: Portrait
152	Special California Schedule P ("SCASP") (xls - 1.30 Mb)	03-01-2012 submit an electronic file in both Pdf and Excel formats & the original of signature pages.	Print Format: Legal size; Orientation: Portrait For insurers licensed to transact workers' compensation insurance in CA or authorized to reinsure the injury, disablement, or death portions of policies of workers' compensation insurance under the class of disability insurance.
152	Special California Schedule P (SCASP) Part VII - Actuarial Certification Q&A's (doc - 61 kb)		Print Format: Letter size; Orientation; Portrait
490	Trusteed Surplus (Must submit to both NAIC Trusteed Surplus Statement (xls ) and CA Trusteed Surplus Statement (xls - )- Department)	03-01-2012	Print Format: Legal size; Orientation: Portrait
	Report of Dividend - CA (xls - 85.5 Mb) Bulletin 93-6		Print Format: Letter size; Orientation: Portrait

Updated Date: 5/16/2012

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