Form MO375-1083 "Life Pbr Statement of Exemption for Insurers Domiciled in Missouri" - Missouri

What Is Form MO375-1083?

This is a legal form that was released by the Missouri Department of Commerce and Insurance - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2020;
  • The latest edition provided by the Missouri Department of Commerce and Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MO375-1083 by clicking the link below or browse more documents and templates provided by the Missouri Department of Commerce and Insurance.

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Download Form MO375-1083 "Life Pbr Statement of Exemption for Insurers Domiciled in Missouri" - Missouri

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STATE OF MISSOURI
LIFE PBR STATEMENT OF EXEMPTION
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FOR INSURERS DOMICILED IN MISSOURI
To be filed before July 1
An insurer domiciled in Missouri planning to elect the Life Principle-Based Reserving (PBR) Exemption for policies issued or assumed in the
current calendar year must file this Statement of Exemption together with the $150 filing fee with the Director of Commerce and Insurance no
later than June 30th of the current calendar year. This Statement of Exemption must also be included with the filing of your company’s June
30th NAIC Quarterly Financial Statement for the calendar year. Exemption requirements are found in Section 376.380.11, RSMo. Note that
these requirements are more stringent than and supersede the requirements in Section II, Subsection 1.D of the Valuation Manual. Please
complete the following information and submit this Statement of Exemption by email to Missouri Department of Commerce and Insurance,
William Leung at InsuranceSolvency@insurance.mo.gov
Reminder: An exemption applies only to policies issued or assumed in the calendar year of the approval, and it applies to all future valuation
dates for those policies. Statements of Exemption must be filed for each calendar year on or after 2020 if the company plans to elect the Life
PBR Exemption for policies issued or assumed in that calendar year.
COMPANY INFORMATION
YEAR FOR WHICH THE STATEMENT OF EXEMPTION APPLIES
NAIC #
NAIC GROUP #
COMPANY NAME
ADDRESS
CITY
STATE
ZIP
CONTACT INFORMATION FOR INDIVIDUAL SIGNING STATEMENT
NAME
PHONE
EMAIL
POLICIES COVERED BY THIS STATEMENT
All policies issued or assumed in the current calendar year that would otherwise be subject to VM-20.
All policies issued or assumed in the current calendar year that would otherwise be subject to VM-20, excluding
INFORMATION REQUIRED FOR MISSOURI DEPARTMENT OF COMMERCE AND INSURANCE TO CONSIDER THE LIFE PBR EXEMPTION
Individual Company
Group
(A) Direct plus assumed from unaffiliated companies ordinary life
premium as reported in Exhibit 1 Part 1, Column 3 in the prior
year annual statement
(B) Confirm the year of the annual statement for reconciling the
amounts reported in (A)
(C) Portion of (A) that is for guaranteed issue policies
(D) Portion of (A) that is for preneed life contracts
(E) Portion of (A) that represent the trasfer of reserves in force as
the effective date of a reinsurance assumed transaction (not
including those related to (C) or (D) above)
(F) Premium amount used for consideration under VM Section II,
Subsection 1.D.2.a, F = A - C - D - E
(G) Confimation that amount in (F) is less that $300M (Individual
Company) and $600M (Group) (Yes/No)
(H) Estimated # of ULSG policies issued or assumed in the current
calendar year where the secondary guarantee fails to meet the
VM-01 definition of a “non-material secondary guarantee”
(I) Confirmation that the company has provided a certification
by a qualified actuary that any ULSG issued after the
operative date of the valuation manual meets the definition
of a nonmaterial secondary guarantee universal life product
(Yes/No or N/A if (H) is 0) If affirmative, the vertification must
accompany this statement.
MO 375-1083 (4-2020)
Life PBR Statement of Exemption for Missouri Domiciled Insurer - Page 1 of 2
STATE OF MISSOURI
LIFE PBR STATEMENT OF EXEMPTION
Save
Print
Reset
FOR INSURERS DOMICILED IN MISSOURI
To be filed before July 1
An insurer domiciled in Missouri planning to elect the Life Principle-Based Reserving (PBR) Exemption for policies issued or assumed in the
current calendar year must file this Statement of Exemption together with the $150 filing fee with the Director of Commerce and Insurance no
later than June 30th of the current calendar year. This Statement of Exemption must also be included with the filing of your company’s June
30th NAIC Quarterly Financial Statement for the calendar year. Exemption requirements are found in Section 376.380.11, RSMo. Note that
these requirements are more stringent than and supersede the requirements in Section II, Subsection 1.D of the Valuation Manual. Please
complete the following information and submit this Statement of Exemption by email to Missouri Department of Commerce and Insurance,
William Leung at InsuranceSolvency@insurance.mo.gov
Reminder: An exemption applies only to policies issued or assumed in the calendar year of the approval, and it applies to all future valuation
dates for those policies. Statements of Exemption must be filed for each calendar year on or after 2020 if the company plans to elect the Life
PBR Exemption for policies issued or assumed in that calendar year.
COMPANY INFORMATION
YEAR FOR WHICH THE STATEMENT OF EXEMPTION APPLIES
NAIC #
NAIC GROUP #
COMPANY NAME
ADDRESS
CITY
STATE
ZIP
CONTACT INFORMATION FOR INDIVIDUAL SIGNING STATEMENT
NAME
PHONE
EMAIL
POLICIES COVERED BY THIS STATEMENT
All policies issued or assumed in the current calendar year that would otherwise be subject to VM-20.
All policies issued or assumed in the current calendar year that would otherwise be subject to VM-20, excluding
INFORMATION REQUIRED FOR MISSOURI DEPARTMENT OF COMMERCE AND INSURANCE TO CONSIDER THE LIFE PBR EXEMPTION
Individual Company
Group
(A) Direct plus assumed from unaffiliated companies ordinary life
premium as reported in Exhibit 1 Part 1, Column 3 in the prior
year annual statement
(B) Confirm the year of the annual statement for reconciling the
amounts reported in (A)
(C) Portion of (A) that is for guaranteed issue policies
(D) Portion of (A) that is for preneed life contracts
(E) Portion of (A) that represent the trasfer of reserves in force as
the effective date of a reinsurance assumed transaction (not
including those related to (C) or (D) above)
(F) Premium amount used for consideration under VM Section II,
Subsection 1.D.2.a, F = A - C - D - E
(G) Confimation that amount in (F) is less that $300M (Individual
Company) and $600M (Group) (Yes/No)
(H) Estimated # of ULSG policies issued or assumed in the current
calendar year where the secondary guarantee fails to meet the
VM-01 definition of a “non-material secondary guarantee”
(I) Confirmation that the company has provided a certification
by a qualified actuary that any ULSG issued after the
operative date of the valuation manual meets the definition
of a nonmaterial secondary guarantee universal life product
(Yes/No or N/A if (H) is 0) If affirmative, the vertification must
accompany this statement.
MO 375-1083 (4-2020)
Life PBR Statement of Exemption for Missouri Domiciled Insurer - Page 1 of 2
INFORMATION REQUIRED FOR MISSOURI DEPARTMENT OF COMMERCE AND INSURANCE TO CONSIDER THE LIFE PBR EXEMPTION CONTINUED
Individual Company
Group
(J) Total adjusted captial as reported in LR033 Column 2 Line 12 in
the prior year RBC statement
(K) Authorized control level risk-based capital asreported in LR031
Column 1 Line 73 in the prior year RBC statement
(L) RBC Ratio = (J)/(K)
(M) Confirmation that (J) is at least 450% of (L) (Yes/No)
(N) Confirmation that the appointed actuary has provided an
unqualified opion on the reserves for the prior calendar year
(Yes/No)
Note: (F) is meant to clarify the term “ordinary life premium” under Section 376.380.11, RSMo.
The policies covered by this statement satisfy the Life PBR Exemption requirements in section 376.380.11, RSMo. The minimum reserve re-
quirements for the ordinary life policies subject to the exemption are those pursuant to applicable methods required in VM-A and VM-C using
the mortality as defined in VM-20 Section 3.C.1 and VM-M Section 1.H.
Any policies issued or assumed in the current calendar year that otherwise would be subject to VM-20 and are not covered by this statement
of exemption will be valued following the requirements of VM-20.
The information contained herein is true and correct to the best of my knowledge and belief.
I certify that the conditions in Section 376.380.11, RSMo are met for the current calendar year based on premiums and other values from
the prior calendar year financial statements.
NAME AND TITLE
SIGNATURE
DATE
Sworn to and subscribed before me this ______________ day of _________________________________________, ________________
My Commission Expires:
____________________
______________________________________________________________________________
Notary Public
MO 375-1083 (4-2020)
Life PBR Statement of Exemption for Missouri Domiciled Insurer - Page 2 of 2
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