Form E-Pc.as-Annual Statement Filings Worksheet November 2000
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1
2Department of Insurance
ATTENTION:
State of Arizona
ANNUAL STATEMENT PREPARER
Financial Affairs Division
THE NAME AND NAIC # OF INSURER MUST
2910 North 44th Street, Second Floor
BE ON ALL FORMS FILED WITH ADOI
Phoenix, Arizona 85018-7256
Telephone: (602) 912-8420/Fax: (602) 912-8421
Property and/or Casualty, Mortgage Guaranty and Prepaid Legal Insurers
Domestic, Foreign and Alien
2000 Annual Statement Filings Worksheet
NAIC:
COMPANY:
DOMICILE:
Enter the greater of policyholders or certificate holders of directly written policies nationwide as of
→
→
12/31/00:→
MUST BE COMPLETED
Initial if
Agency
Enclosed
Initial at left if items are enclosed with 2000 Annual Statement
Use Only
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SECTION 1: DOMESTIC, FOREIGN AND ALIEN INSURERS:
_______
A. Annual Statement - 8-1/2” x 14” (YELLOW JACKET, SECURELY BOUND in two-sided book form).......................... _________
WHICH MUST INCLUDE TO BE COMPLETE:
_______
1.
Jurat Page .................................................................................................................................................................... _ _ _ _ _ _ _
_______
a.
Two Authorized Original Signatures ................................................................................................................... _ _ _ _ _ _ _
(SIGNERS NAMES MUST BE LISTED ON THE 2000 JURAT PAGE)
_______
b.
Notarized signatures ...........................................................................................................................................
_______
2.
Actuarial Opinion OR ................................................................................................................................................. _________
PROVIDE AN AFFIDAVIT OF EXEMPTION:
a.
DOMESTIC INSURERS (Copy of the Arizona Insurance Department’s Approval letter MUST
_______
accompany Affidavit) .......................................................................................................................................... _________
b.
FOREIGN AND ALIEN INSURERS (Copy of Domiciliary Commissioner Approval letter MUST
accompany Affidavit) .......................................................................................................................................... _________
_______
3.
ARIZONA State Page 15 (Domestic Insurers also Include all other states and Mexico, if applicable)..................... _________
_______
B.
Form E-178 Certificate of Disclosure................................................................................................................................. _________
WHICH MUST INCLUDE TO BE COMPLETE:
_______
1.
Part A must be answered yes or no (If yes, must have attachment) .............................................................................
_______
2.
Part B must be answered yes or no (If yes, must have attachment) .............................................................................
_______
3.
Two Executive Officer Original Signatures ..............................................................................................................
(SIGNERS NAMES MUST BE LISTED ON THE 2000 JURAT PAGE)
_______
a.
Notary signature and stamp or seal .....................................................................................................................
_______
C.
Form E-PC.175 Supplement "B" to Schedule T - Arizona Only (If none, stamp “NONE” on form and return) ............... _________
_______
D. Management Discussion & Analysis with completed Transmittal Form E-MDA (if available and enclosed) .................. _________
The transmittal form MUST be completed and affixed to report. DO NOT mail transmittal form without report attached.
_______
E.
Annual Audited Financial Report with completed Transmittal Form E-AFR (if available and enclosed) ........................ _________
The transmittal form MUST be completed and affixed to report. DO NOT mail transmittal form without report attached.
MORTGAGE GUARANTY INSURERS ONLY:
_______
F.
Form E-MG.MPP Mortgage Guaranty Insurers Report of Policyholders Position ........................................................... _________
_______
G. Supplementary Schedule F-5 Unauthorized Reinsurance MARKED “CONFIDENTIAL” (see instruction
Form E-MG.CEDE) .......................................................................................................................................................... _________
INITIAL TO CONFIRM THAT THE FOLLOWING REPORTS HAVE BEEN OR WILL BE SENT UNDER SEPARATE
MAILING TO ATTENTION: LIFE AND HEALTH DIVISION. DO NOT MAIL IN ANNUAL STATEMENT ENVELOPE.
H. HIPAA-3/1, HIPAA-I, HIPAA-II, and HIPAA-III (Must submit these forms. If not applicable, enter “N/A” on the form and
_______
return).................................................................................................................................................................................. _________
E-PC.AS (11/00)
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