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Form Slb-Final - Az Surplus Lines Broker Final Statement And Premium Tax Report - 2004

ARIZONA DEPARTMENT OF INSURANCE

Financial Affairs Division

COMPLIANCE SECTION

2910 NORTH 44TH STREET, SECOND FLOOR

Phoenix, Arizona 85018-7256

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

ARIZONA SURPLUS LINES BROKER FINAL STATEMENT AND PREMIUM TAX REPORT

FOR REPORTING PERIOD OF:

THROUGH

DATE OF SURPLUS LINES BROKER LICENSE TERMINATION:

DUE WITHIN 30 DAYS OF THE SURPLUS LINES LICENSE TERMINATION

READ FORM E-SLB-F

“FINAL STATEMENT AND PREMIUM TAX REPORT FORMS AND INVENTORY INSTRUCTIONS” BEFORE

INAL

NSTRUCTION

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 Final Statement must be executed and notarized to be considered a complete filing **

OATH

State of

} ss

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 ________________________ , Year_______.

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 Arizona Surplus Lines Brokers

whose activity and reporting for any part of the preceding six months may be related to your surplus

lines activity and reporting.