MISSOURI DEPARTMENT OF COMMERCE AND INSURANCE
ANNUAL STATEMENT SUPPLEMENT FOR MISSOURI


FOR YEAR ENDING 2019
DUE DATE - MARCH 1 SEE INSTRUCTIONS ON REVERSE SIDE
COMPANY
NAIC GROUP NUMBER
NAIC COMPANY NUMBER
PERSON COMPLETING FORM
TELEPHONE NUMBER
EMAIL
LIFE INSURANCE I II III IV V VI
INDIVIDUAL BUSINESS NUMBER OF INSUREDS DIRECT PREMIUM & ANNUTIY CONSIDERATIONS DIRECT DIVIDENDS TO POLICYHOLDER DIRECT CLAIMS, BENFITS & SURRENDER VALUES PAID LIFE INSURANCE IN FORCE (000) DECEMBER 31
1.1) Whole
1.2) Term
1.3) Universal
1.4) Graded Death Benefits
1.5) Credit
1.6) Variable Life
1.7) Annuities (with life contingencies)
a) Ordinary
b) Variable
c) Modified Guaranteed
d) Equity Indexed
1.8) Deposit-Type Contract Funds
(including variable contracts without life contingencies)
1.9) Other Considerations
1.10) TOTAL INDIVIDUAL
GROUP BUSINESS
2.1) Whole
2.2) Term
2.3) Universal
2.4) Graded Death Benfits
2.5) Credit
2.6) Variable Life
2.7) Annuities (with life contingencies)
a) Ordinary
b) Variable
c) Modified Guaranteed
d) Equity Indexed
2.8) Deposit-Type Contract Funds
(including variable contracts without life contingencies)
2.9) Other Considerations
2.10) TOTAL GROUP
3) TOTAL LIFE
ACCIDENT AND HEALTH INSURANCE I II III IV V VI
INDIVIDUAL BUSINESS NUMBER OF INSUREDS DIRECT PREMIUMS WRITTEN DIRECT PREMIUMS EARNED DIVIDENDS PAID OR CREDITED ON DIRECT BUSINESS DIRECT LOSSED PAID DIRECT LOSSED INCURRED
4.1) Comprehensive Medical Expense
(see definition above)
4.2) Medicare Supplement
4.3) Long Term Care
4.4) Specified Disease
4.5) Accident Only
4.6) Disability Income
4.7) Dental
4.8) Limited Benefit
4.9) Short Term Credit Disability
(less than 10 years)
4.10) Long Term Credit Disability (Mortgage)
4.11) Credit Unemployment
4.12) Stop Loss
4.13) Medicare Part D
4.14) Medicare Advantage/Medicare PPO Product
4.15) TOTAL INDIVIDUAL
GROUP BUSINESS
5.1) Comprehensive Medical Expense
a) Small employer (2-50 employees)
b) Large employer/union
(over 50 employees)
c) Association
d) Discretionary
e) Federal Employees (line 23.1)
5.2) Medicare Supplement
5.3) Long Term Care
5.4) Specified Disease
5.5) Accident Only
5.6) Disability Income
5.7) Dental
5.8) Limited Benefit
5.9) Short Term Credit Disability (less than 10 years)
5.10) Long Term Credit Disability
(Mortgage)
5.11) Credit Unemployment
5.12) Stop Loss
5.13) Medicatet Part D
5.14) Medicare Advantage/Medicare PPO Product
5.15) TOTAL GROUP
6) ALL ACCIDENT & HEALTH
7.1) Small employer (3-25) employees
7.2) Number of insured employers reported on Line 5.1a:
7.3) Number of insured employers reported on Line 7.1:
8.1) Small employers (3-25 employees) in associations with rate differentials exceeding 20 percent.
8.2) Small Employers (3-25 employees) in associations with rate differentials NOT exceeding 20%
8.3) Large employers in association plans with rate differentials exceeding 20%
8.4) Large employers in association plans with rate differentials NOT exceeding 20%
8.1a) Number of insured employers reported on Line 8.1:
8.2a) Number of insured employers reported on Line 8.2:
8.3a) Number of insured employers reported on Line 8.3:
8.4a) Number of insured employers reported on Line 8.4:

DEFINITIONS FOR SPECIFIC LINES OF BUSINESS

NUMBER OF INSUREDS AS OF DECEMBER 31 OF REPORT YEAR:
For individual policies, the number of insureds must include dependents. For group policies, the number of insureds must equal the number of certificate holders, plus all dependents.
COMPREHENSIVE MEDICAL EXPENSE:
This category includes major medical, comprehensive medical and other hospital-surigal-medical benefit plans designed to be the insured person's primary health benefit coverage. Do not include plans covering less than 50% of incurred expenses.
LIMITED BENEFIT:
Includes vision, nursing care (other than long-term care), hospital indemnity and any other single service plan or program, not otherwise reported herein.
SMALL EMPLOYER:
(2-50 employees) (Line 5.1a): This term means major medical or comprehensive group medical expense insurance coverage that is subject to the group market provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA).
ASSOCIATION:
(Line 5.1c): This term means major medical or comprehensive group medical expense insurance coverage sold to members of associations THAT IS NOT subject to the group market provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA).
SMALL EMPLOYER:
(3-25 employees) (Line 7.1): This term means major medical or comprehensive group medical expense coverage that is subject to The Missouri Small Employer Health Insurance Availability Act.
STOP LOSS:
Include any premium for employer self-funded group health plan excess loss coverage, including any such coverage issued or provided through minimum premium plans or other self funded health benefit plans.
MEDICARE PART D:
Pursuant to the Medicare Modernization Act, companies writing prescription drug coverage, through Medicare Part D, must report their data on line numbers 4.13 and/or 5.13.
MEDICARE ADVANTAGE:
A plan of coverage for health benefits under Medicare Part C as defined in Section 1859 found in Title IV, Subtitle A, Chapter 1 of P.L. 105-33.
ADDITIONAL ASSOCIATION INFORMATION(LINES 8.1 THROUGH 8.4):
Report only business that offers coverage to associations that include both small (3-25 employees) and large employers. Please refer to the instructions that were included in your packet for additional information.

If additional definitions are needed for detail lines of business, please send a self-addressed stamped envelope to this office (no phone calls please).

EXPLANATION IF PREMIUMS ARE REPORTED, BUT NO INSUREDS: