Form E-Ppd.as - Annual Statement Filings Worksheet November 2000

Department of Insurance

ATTENTION:

State of Arizona

ANNUAL STATEMENT PREPARER

Financial Affairs Division

THE NAME AND NAIC # OF INSURER MUST BE

2910 North 44th Street, Second Floor

ON ALL FORMS FILED WITH ADOI

Phoenix, Arizona 85018-7256

Telephone: (602) 912-8420/Fax: (602) 912-8421

Prepaid Dental Organization - Domestic

2000 Annual Statement Filings Worksheet

NAIC: _______ COMPANY: ________________________________________________

DOMICILE: AZ

Enter Company Figures

Enter Company Figures

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Assets:

AZ Medicaid Title XIX:

(Page 2, Line 22, Col. 3)

(Page 56, Line 3, Col. 6)

$

$

Liabilities:

AZ Federal Employee Health

(Page 3, Line 15, Col. 3)

Benefits Program Premiums:

$

$

(Page 56, Line 3, Col. 7)

Common Stock:

All Premiums:

(Page 3, Line 16, Col. 3)

(Page 56, Line 58, Col. 4)

$

$

Preferred Stock:

All Medicare Title XVIII:

(Page 3, Line 17, Col. 3)

(Page 56, Line 58, Col.5)

$

$

Total Net Worth:

All Medicaid Title XIX:

(Page 3, Line 24, Col. 3)

(Page 56, Line 58, Col. 6)

$

$

AZ Premiums:

All Federal Employee Health

(Page 56, Line 3, Col. 4)

Benefits Program Premiums:

$

$

(Page 56, Line 58, Col. 7)

AZ Medicare Title XVIII:

Number of Members - Current

(Page 56, Line 3, Col. 5)

Year End:

$

#

(Page 8, Line 4, Col. 5)

Initial if

Initial at left if items are enclosed with 2000 Annual Statement

Agency

Enclosed

Use Only

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A. Annual Statement – 8-1/2" X 14" (MAROON JACKET, SECURELY BOUND in two-sided book form) ..................... _________

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

THE FOLLOWING REPORTS MUST BE ATTACHED TO THIS WORKSHEET:

_______

B.

Calendar Year 2000 Financial Statement Certified by Independent Public Accountant ................................................... _________

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C.

Form E-186 - Annual Report Supplement........................................................................................................................ _________

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D. Form E-PPD.SM - Significant Modification Report (See Page 3 of Instruction Form E-PPD.I) .................................... _________

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E.

Supplemental Compensation Exhibit ................................................................................................................................ _________

_______

F.

Copy of Managed Care Organizations RBC Formula Computation report. (See Form E-PPD.I, Item 5B) ...................... _________

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G. Management Discussion & Analysis with Transmittal Form E-MDA (if available and enclosed) .................................. _________

Transmittal form MUST be completed and affixed to report. DO NOT mail transmittal form without the report attached.

INITIAL TO CONFIRM THAT THE FOLLOWING REPORTS HAVE BEEN OR WILL BE SENT UNDER SEPARATE

MAILING TO ATTENTION: COMPLIANCE SECTION. DO NOT MAIL IN ANNUAL STATEMENT ENVELOPE.

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H. Annual Insurance Holding Company Registration Statement Forms B and C

PREPARED BY:

__________________________________________________________________

_________________________________________

Name Title

Collect / Toll Free Phone Number

E-MAIL ADDRESS, if available:

E-PPD.AS (11/00)

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