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

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ARIZONA DEPARTMENT OF INSURANCE

Financial Affairs Division

COMPLIANCE SECTION

2910 NORTH 44TH STREET, SUITE 210

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-FINAL.I

“FINAL STATEMENT AND PREMIUM TAX REPORT FILING INSTRUCTIONS” BEFORE

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

}

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

Arizona Surplus Lines Brokers whose activity and reporting for any part of this