NAIC BLANKS (E) WORKING GROUP
Blanks Agenda Item Submission Form
DATE:

02/21/2020

CONTACT PERSON:TELEPHONE:

FOR NAIC USE ONLY
Agenda Item # 2020-22BWG MOD
Year
2020
Changes to Existing Reporting[X ]New Reporting Requirement[ ]EMAIL ADDRESS:REVIEWED FOR ACCOUNTING
PRACTICES AND PROCEDURES IMPACT

ON BEHALF OF:

No Impact [ X ]Modifies Required Disclosure [DISPOSITION

NAME:

Dale Bruggeman

TITLE:

Chair SAPWG

AFFILIATION:

Ohio Department of Insurance

ADDRESS:

50W. Town St., 3rd Fl., Ste. 300

[
]
[
]
[
]
[ X ]
[
]
[
]
[
]

Columbus, OH 43215]

Rejected For Public Comment
Referred To Another NAIC Group
Received For Public Comment
Adopted Date 08/27/2020
Rejected Date
Deferred Date
Other (Specify)

BLANK(S) TO WHICH PROPOSAL APPLIES[ X ] ANNUAL STATEMENT[] QUARTERLY STATEMENT[ X ] INSTRUCTIONS[ X ] BLANK[] CROSSCHECKS[ X ] Life, Accident & Health/Fraternal[ X ] Property/Casualty[ X ] Health[] Separate Accounts[ X ] Protected Cell[
] Health (Life Supplement)[ X ] Title[] Other _______________________

Anticipated Effective Date: Annual 2021
IDENTIFICATION OF ITEM(S) TO CHANGE
Modify the instructions and illustration for Note 3A and a new Note 3E with instructions and illustrations to be data captured.
Modify the blank and instructions for Schedule D, Part 6, Sections 1 and 2.
REASON, JUSTIFICATION FOR AND/OR BENEFIT OF CHANGE**
The purpose of this proposal is to make changes to the disclosures in the Notes to Financial Statement and Schedule D, Part 6
to reflect changes being adopted for SSAP No. 68—Business Combinations and Goodwill and SSAP No. 97—Investments in
Subsidiary, Controlled and Affiliated Entities by Statutory Accounting Principles (E) Working Group (SAPWG).
NAIC STAFF COMMENTS
Comment on Effective Reporting Date:
Other Comments:
Proposal is being exposed concurrently with SSAP changes being considered by SAPWG.
___________________________________________________________________________________________________** This section must be completed on all forms.
Revised 7/18/2018© 2020 National Association of Insurance Commissioners

12020-22BWG_Modified.doc

ANNUAL STATEMENT INSTRUCTIONS – LIFE/FRATERNAL, HEALTH, PROPERTY AND TITLENOTES TO FINANCIAL STATEMENTS

Detail Eliminated to Conserve Space
3.

Business Combinations and Goodwill
Instruction:
A.

Statutory Purchase Method
For business combinations accounted for under the statutory purchase method, disclose the following for as
long as unamortized goodwill is reported as a component of the investment:The name and brief description of the acquired entity.

That the method of accounting is the statutory purchase method.

Acquisition date, cost of the acquired entity, the original amount of goodwill and the original amountof admitted goodwill.



TheEach SCA’s book value, the amount of amortization amortized of goodwill recorded for the period,
and the SCA’s admitted goodwill as of the reporting date andTotal admitted goodwill as of the reporting date

admitted Admitted goodwill as a percentage of the SCA’s book adjusted carrying value (gross ofadmitted goodwill). (Admitted goodwill as of the reporting date divided by book value of the SCA.

Detail Eliminated to Conserve SpaceD.

Impairment Loss
If an impairment loss was recognized, disclose the following in the period of the impairment write-down:

E.

(1)

A description of the impaired assets and the facts and circumstances leading to the impairment,
and

(2)

The amount of the impairment charged to realized capital gains and losses and how fair value wasdetermined.

Subcomponents and Calculation of Adjusted Surplus and Total Admitted Goodwill
A reporting shall disclose the subcomponents and calculation of adjusted surplus and total admitted
goodwill as a percentage of adjusted surplus.

© 2020 National Association of Insurance Commissioners

22020-22BWG_Modified.doc

Illustration:
A.

Statutory Purchase Method
The Company purchased 100% interest of XYZ Insurance Company on 6/30/_____. XYZ Insurance
Company is licensed in 49 states and sells workers’ compensation products exclusively.

THIS EXACT FORMAT MUST BE USED IN THE PREPARATION OF THIS NOTE FOR THE TABLE BELOW.
REPORTING ENTITIES ARE NOT PRECLUDED FROM PROVIDING CLARIFYING DISCLOSURE BEFORE
OR AFTER THESE ILLUSTRATIONS.
The transaction was accounted for as a statutory purchase and reflects the following:
1

2

Purchased entity.............................................................................
.............................................................................
.............................................................................
.............................................................................
.............................................................................

Acquisitiondate.....................
.....................
.....................
.....................
.....................

3

4

5

6

Cost of acquired
entity$ .........................
$ .........................
$ .........................
$ .........................
$ .........................

Original amountof admitted
goodwill$ ........................
$ ........................
$ ........................
$ ........................
$ ........................

Admitted
goodwill as of thereporting date$ ........................
$ ........................
$ ........................
$ ........................
$ ........................

Amount of
goodwill
amortized during
the reporting
period$ ........................
$ ........................
$ ........................
$ ........................
$ ........................

1

2

Purchased entity.............................................................................................
.............................................................................................
.............................................................................................
.............................................................................................
Totlal ...................................................................................

Acquisition date.........................
.........................
.........................
.........................
XXX

3
Cost of acquired
entity$ ................................
$ ................................
$ ................................
$ ................................
$ ................................

4
Original amountof goodwill$ ................................
$ ................................
$ ................................
$ ................................
$ ................................

7
Admitted
goodwill
as a % of
SCA
BACV,gross ofadmitted
goodwill.............%.............%.............%.............%.............%

5
Original amount ofadmitted goodwill$ ................................
$ ................................
$ ................................
$ ................................
$ ................................

1

6

7

8

Purchased entity.............................................................................................
.............................................................................................
.............................................................................................
.............................................................................................
Total ....................................................................................

Admitted goodwill asof the reporting date$ ................................
$ ................................
$ ................................
$ ................................
$ ................................

Amount of goodwill
amortized during thereporting period$ ................................
$ ................................
$ ................................
$ ................................
$ ................................

Book Value of SCA$ ................................
$ ................................
$ ................................
$ ................................
$ ................................

9
Admitted
goodwill as a %of SCA BACV,
gross ofadmitted
goodwill
Col. 6/Col. 8...................... %...................... %...................... %...................... %XXX%

Detail Eliminated to Conserve Space© 2020 National Association of Insurance Commissioners

32020-22BWG_Modified.doc

D.

Impairment Loss
The Company did not recognize an impairment loss on the transactions described above.

THIS EXACT FORMAT MUST BE USED IN THE PREPARATION OF THIS NOTE FOR THE TABLE BELOW.
REPORTING ENTITIES ARE NOT PRECLUDED FROM PROVIDING CLARIFYING DISCLOSURE BEFORE
OR AFTER THESE ILLUSTRATIONS.
E.

Subcomponents and Calculation of Adjusted Surplus and Total Admitted Goodwill
Calculation ofLimitation Using
Prior Quarter
Numbers..............................

Current Reporting
PeriodXXX..............................
..............................
..............................

XXX
XXX
XXX

(5) Adjusted Capital and Surplus (Line 1-+2-+3-+4)..............................

XXX(6) Limitation on amount of goodwill (adjusted capital and surplus times 10%
goodwill limitation [Line 5*10%])..............................

XXX

XXX

..............................

XXX............................. %(1) Capital & Surplus
Less:(2) Admitted Positive Goodwill(3) Admitted EDP Equipment & Operating System Software(4) Admitted Net Deferred Taxes(7) Current period reported Admitted Goodwill(8) Current Period Admitted Goodwill as a % of prior period Adjusted
Capital and Surplus (Line 7/Line 5)

Detail Eliminated to Conserve Space© 2020 National Association of Insurance Commissioners

42020-22BWG_Modified.doc

SCHEDULE D – PART 6 – SECTION 1
VALUATION OF SHARES OF SUBSIDIARY, CONTROLLED OR AFFILIATED COMPANIES

Detail Eliminated to Conserve Space
Column 7–

Do Insurer’s Assets Include Intangible Assets Connected with Holding of Such Company’s Stock?
State whether the assets shown by the reporting entity in this statement include, through the carrying
value of stock of the SCA company valued under the SSAP No. 97—Subsidiary, Controlled andAffiliated Entities, intangible assets arising out of the purchase of such stock by the reporting entity or
the purchase by the SCA Company of the stock of a lower-tier company controlled by the SCA
Company. For purposes of this question, intangible assets at purchase shall be defined as the excess ofthe purchase price over the tangible net worth (total assets less intangible assets and total liabilities)
represented by such shares as recorded, immediately prior to the date of purchase, on the books of thecompany whose stock was purchased.

Column 8–

Total Amount of Such Intangible AssetsGoodwill
If the answer in Column 7 is “Yes,” give the total amount of intangible assets involved whether
admitted or nonadmitted. The intangible assetsgoodwill shown for the SCA Company should include
any intangible assets that are included in the SCA Company’s carrying value of the stock of one ormore lower-tier companies controlled by the SCA Company. In all cases, the current intangible
assetsgoodwill equals the intangible assetsgoodwill calculated at purchase, as defined in SSAP No.
68—Business Combinations and Goodwillabove, minus any write-off thereof between the date ofpurchase and the statement date. If any portion of the total amount of intangible assetsgoodwill isrequired to be nonadmitted for all SCA companies combined in accordance with SSAP No. 97—
Investments in Subsidiary, Controlled and Affiliated Entities and SSAP No. 68—Business
Combinations and Goodwill state the total amount nonadmitted in the footnote at the bottom of the thissection of the schedule.

Column 109–

Nonadmitted Amount
Provide the amount nonadmitted, if any, included in Column 2 of the Asset page.

Column 1110 –Column 1211 –Stock of Such Company Owned by Insurer on Statement Date Number of Shares andStock of Such Company Owned by Insurer on Statement Date % of Outstanding}

State the number of shares of stock of the SCA Company owned by the reporting entity on thestatement date and the percent owned of the outstanding shares of the same class.
** Column 13 12 through 16 15 will be electronic only. **Column 1312 –Legal Entity Identifier (LEI)
Provide the 20-character Legal Entity Identifier (LEI) for any issuer as assigned by a designated Local
Operating Unit. If no LEI number has been assigned, leave blank.

© 2020 National Association of Insurance Commissioners

52020-22BWG_Modified.doc

Column 1413 –IssuerIssuer Definition:
The name of the legal entity that develops, registers and sells securities for the purpose offinancing its operations and may be domestic or foreign governments, corporations or investment
trusts. The issuer is legally responsible for the obligations of the issue and for reporting financial
conditions, material developments and any other operational activities as required by theregulations of their jurisdictions
Do not report ticker symbols, either internal or otherwise.
The issuer information should be the same as provided for Schedule D, Part 2, Sections 1 and 2.

Column 1514 –Issue
Issue information provides detailed data as to the type of security being reported.
Do not report ticker symbols, either internal or otherwise.
The issue information should be the same as provided for Schedule D, Part 2, Sections 1 and 2.

Column 1615 –ISIN Identification
The International Securities Identification Numbering (ISIN) system is an international standard set upby the International Organization for Standardization (ISO). It is used for numbering specificsecurities, such as stocks, bonds, options and futures. ISIN numbers are administered by a National
Numbering Agency (NNA) in each of their respective countries, and they work just like serial numbers
for those securities. Record the ISIN number only if no valid CUSIP, CINS or PPN exists to report inColumn 1.

SCHEDULE D – PART 6 – SECTION 2

Detail Eliminated to Conserve Space
Column 4–

Total Amount of Intangible AssetsGoodwill Included in Amount Shown in Column 8, Section 1
As explained in the instructions for Section 1, this amount is based on the intangible assetsgoodwill atpurchase of the stock of the lower-tier company, reduced by any subsequent impairment/write-off. The
reporting entity also bases the amount shown on the proportionate ownership of the lower-tiercompany.

Detail Eliminated to Conserve Space© 2020 National Association of Insurance Commissioners

6}2020-22BWG_Modified.doc

ANNUAL STATEMENT BLANK – LIFE/FRATERNAL, HEALTH, PROPERTY AND TITLESCHEDULE D – PART 6 – SECTION 1
Valuation of Shares of Subsidiary, Controlled or Affiliated Companies
1

2

CUSIP
Identification.....................
.....................
.....................
.....................
.....................
.....................
.....................
.....................
.....................
.....................
.....................
.....................
.....................
.....................
.....................

3

Description Nameof Subsidiary, Controlled or
Affiliated Company..................................................
..................................................
..................................................
..................................................
..................................................
..................................................
..................................................
..................................................
..................................................
..................................................
..................................................
..................................................
..................................................
..................................................
..................................................

Foreign...............
...............
...............
...............
...............
...............
...............
...............
...............
...............
...............
...............
...............
...............
...............

4

NAIC Company Code.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................
.........................................

5

ID Number......................
......................
......................
......................
......................
......................
......................
......................
......................
......................
......................
......................
......................
......................
......................

6

7

8

9

109

NAIC Valuation
Method.................................
.................................
.................................
.................................
.................................
.................................
.................................
.................................
.................................
.................................
.................................
.................................
.................................
.................................
.................................

Book/Adjusted Carrying
Value Do Insurer's Assets
Include Intangible Assets
Connected with Holding of
Such Company's Stock?
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................

Total Amount ofGoodwill Included in
Book/Adjusted
Carrying Value Such
Intangible Assets..................................
..................................
..................................
..................................
..................................
..................................
..................................
..................................
..................................
..................................
..................................
..................................
..................................
..................................
..................................

Book /
Adjusted
Carrying Value............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................

Nonadmitted
Amount..........................
..........................
..........................
..........................
..........................
..........................
..........................
..........................
..........................
..........................
..........................
..........................
..........................
..........................
..........................

1999999 Totals
1.
12.

Stock of Such
Company Owned by
Insurer on Statement Date
1110
1211
Numberof% of
SharesOutstanding......................
....................
......................
....................
......................
....................
......................
....................
......................
....................
......................
....................
......................
....................
......................
....................
......................
....................
......................
....................
......................
....................
......................
....................
......................
....................
......................
....................
......................
....................
XXX

XXX

Amount of insurer’s capital and surplus from the prior period’s statutory statement reduced by any admitted EDP, goodwill and net deferred tax assets included therein: $.....................................
Total amount of intangible assetsgoodwill nonadmitted $ .........................

SCHEDULE D – PART 6 – SECTION 2
1

2

3

CUSIP
Identification.........................
.........................
.........................
.........................
.........................
.........................
.........................
.........................
.........................
.........................
.........................
.........................
.........................
.........................
.........................

Name ofLower-Tier Company...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................

Name of Company Listed in Section 1
Which Controls Lower-Tier Company........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................

4
Total Amount of Intangible AssetsGoodwill
Included in Amount Shown in Column 8, Section1................................................................................
................................................................................
................................................................................
................................................................................
................................................................................
................................................................................
................................................................................
................................................................................
................................................................................
................................................................................
................................................................................
................................................................................
................................................................................
................................................................................
................................................................................

0399999 Total

Stock in Lower-Tier Company
Owned Indirectly by Insurer on Statement Date
5
6
Number of Shares% of Outstanding....................................................................................
...................................................................................
....................................................................................
...................................................................................
....................................................................................
...................................................................................
....................................................................................
...................................................................................
....................................................................................
...................................................................................
....................................................................................
...................................................................................
....................................................................................
...................................................................................
....................................................................................
...................................................................................
....................................................................................
...................................................................................
....................................................................................
...................................................................................
....................................................................................
...................................................................................
....................................................................................
...................................................................................
....................................................................................
...................................................................................
....................................................................................
...................................................................................
....................................................................................
...................................................................................
XXX

XXX

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