Form E-Sl-2 - Az Surplus Lines Broker Semi-Annual Statement And Premium Tax Report - 2004

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ARIZONA DEPARTMENT OF INSURANCE

Financial Affairs Division

DUE ON OR BEFORE MARCH 1, 2005

COMPLIANCE SECTION

2910 NORTH 44TH STREET, SUITE 210

Phoenix, Arizona 85018-7256

Phone: (602) 912-8427 Fax: (602) 912-8421

ARIZONA SURPLUS LINES BROKER

SEMI-ANNUAL STATEMENT AND PREMIUM TAX REPORT - JULY 1, 2004 through DECEMBER 31, 2004

READ FORM E-SL-2.I

“2004 ARIZONA SURPLUS LINES BROKER SEMI-ANNUAL STATEMENT AND PREMIUM TAX REPORT

NSTRUCTION

FILING INSTRUCTIONS” BEFORE PROCEEDING TO PREPARE AND FILE THIS REPORT.

Arizona License Number

Name on License

Mailing Address

Telephone #:

FAX #

E-Mail Address:

PART B - AFFIDAVIT OF BROKER UNDER OATH

** This Semi-Annual Statement must be executed and notarized to be considered a complete filing **

OATH

State of

}

County of

}

I ____________________________________________________________, being duly sworn, depose and say that I am now, or was

(Type or Print Complete Name of Affiant)

during the preceding six months, a duly licensed Arizona Surplus Lines Broker, or, I am duly authorized to execute this statement on behalf of the

licensed corporation named below in my capacity as

(Title)

and that the information contained in Part A on Page 2 of this report, including any attachments thereto, is complete, true and correct to the best of

my knowledge and belief.

Type Name of Licensed Corporation, if applicable:

Signature of Affiant Broker or Authorized

Official on behalf of a Licensed Corporation

Subscribed and sworn to before me this _________ day of ________________________ , ________.

My commission expires:

(Notary Public)

SEAL

(

)

To assist in cross-referencing and reconciling our records, please provide the names

and Arizona license numbers of other individuals or corporations licensed as