Form E-Fraternal.as - Fraternal Benefit Societies - Foreign And Alien - Annual Statement Filings Worksheet - 2000

Department 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

Fraternal Benefit Societies − − − − 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

Initial at left if items are enclosed with 2000 Annual Statement

Agency

Enclosed

Use Only

↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓

_______

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

WHICH MUST INCLUDE TO BE COMPLETE:

_______

1.

Jurat Page ..................................................................................................................................................................

_______

a.

Two Authorized Notarized Signatures...............................................................................................................

(SIGNERS NAMES MUST BE LISTED ON THE 2000 JURAT PAGE)

_______

2.

Actuarial Opinion ...................................................................................................................................................... _________

_______

3.

ARIZONA State Page 20 .......................................................................................................................................... _________

THE FOLLOWING REPORTS MUST BE ATTACHED TO THIS WORKSHEET:

_______

B.

Form E-178 Certificate of Disclosure................................................................................................................................ _________

WHICH MUST INCLUDE TO BE COMPLETE:

_______

1.

E-178, Part A must be answered yes or no (If yes, must have attachment) ...............................................................

_______

2.

E-178, 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....................................................................................................................

IF THE FOLLOWING REPORTS ARE AVAILABLE, PLEASE ATTACH TO THIS WORKSHEET:

_______

C.

Management Discussion & Analysis with 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.

_______

D. Annual Audited Financial Report with 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.

PREPARED BY:

______________________________________________________________________

_______________________________________

Name & Title

Collect / Toll Free Phone Number

E-MAIL ADDRESS, if available

E-FRATERNAL.AS (11/00)

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