Form E-Title.as - Title Insurer - Domestic, Foreign And Alien 2000 Annual Statement Filings 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

Title Insurer – Domestic, Foreign and Alien

2000 Annual Statement Filings Worksheet

NAIC: _____ COMPANY: ______________________________________________

DOMICILE:

Enter the greater of policy holders 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

↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓

↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓

SECTION 1: DOMESTIC, FOREIGN AND ALIEN INSURERS:

_______

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

WHICH MUST INCLUDE TO BE COMPLETE:

_______

1.

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

_______

a.

Two Authorized Signatures (Original signatures Domestic companies only) .............................................................

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

_______

b.

Notarized Signatures ...........................................................................................................................................

_______

2.

Actuarial Opinion OR provide an Affidavit of Exemption.......................................................................................... _________

a.

DOMESTIC INSURER: Copy of Arizona Exemption Approval must accompany Affidavit.............................

b.

FOREIGN AND ALIEN INSURER: Copy of Domiciliary Commissioner Approval letter must accompany

Affidavit ..............................................................................................................................................................

_______

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.

E-178, Part D must be answered yes or no ..................................................................................................................

_______

4.

Two Executive Officer Original Signatures.................................................................................................................

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

_______

a.

Notary signature and stamp or seal......................................................................................................................

_______

C.

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.

D. Annual Audited Financial Report with Transmittal Form E-AFR (if available and enclosed) ......................................... _________

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

SECTION II: DOMESTIC INSURER ONLY:

_______

A. ONE ENTIRE DUPLICATE of the 8-1/2” x 14” Hard Copy Annual Statement, including all bound pages

and loose supplemental pages is required. This duplicate statement must be stamped "COPY" on the front page.

You must enclose the Duplicate Annual Statement Filings Worksheet Form E-TITLE.DUP in your duplicate

filing

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

THE FOLLOWING REPORTS MUST BE ATTACHED TO THIS WORKSHEET:

OR

..................................................................................... _________

_______

B.

Copy of NAIC Annual Statement Diskette Transmittal Form

_______

1.

Annual Electronic Filing Transmittal Form and Certification (if filing with NAIC VIA INTERNET)....................... _________

_______

C.

Copy of SVO Compliance Certification.............................................................................................................................. _________

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.

_______

D. 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-TITLE.AS (11/00)

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