Form E-Rrg.as - Risk Retention Group - 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

Risk Retention Group − − − − Foreign and Alien

2000 Annual Statement Filings Worksheet

NAIC: _____

COMPANY: __________________________________________ DOMICILE: ____

Enter Company Figures Here

Enter Company Figures Here

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Assets:

AZ Direct Premiums:

(Page 2, Line 22, Col. 4)

(Page 132, Line 3, Col. 2)

Liabilities:

AZ Finances & Service Charges:

(Page 3, Line 23, Col. 1)

(Page 132, Line 3, Col. 8)

Common Capital:

AZ Purchasing Group Premiums:

(Page 3, Line 25A, Col. 1)

(Page 132, Line 3, Col. 9)

Preferred Capital:

All Direct Premiums:

(Page 3, Line 25B, Col. 1)

(Page 132, Line 58, Col. 2)

Policyholders Surplus:

All Finances & Service Charges:

(Page 3, Line 27, Col. 1)

(Page 132, Line 58, Col.8)

Reinsurance Assumed Affiliates:

Number of Policyholders Nationwide

(Page 9, Line 32, Col. 2a)

as of 12/31/2000:

Reinsurance Assumed Non-Affiliates:

(Page 9, Line 32, Col. 2b)

Initial if

Initial at left if items are enclosed with 2000 Annual Statement

Agency

Enclosed

Use Only

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_______

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

INCLUDE, IF APPLICABLE:

_______

1.

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

_______

a.

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

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

_______

2.

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

_______

a.

Affidavit of Exemption (Copy of Domiciliary Commissioner Approval MUST accompany Affidavit) ...........

_______

3.

ARIZONA State Page 15 .......................................................................................................................................... _________

THE FOLLOWING REPORTS MUST BE ATTACHED TO THIS WORKSHEET:

Form E-PC.175 Supplement "B" to Schedule T - Arizona Only (if none, return stamped “NONE”).............................. _________

_______

B.

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

_______

C.

Management Discussion & Analysis with completed Transmittal Form E-MDA ........................................................... _________

The transmittal form MUST be completed and affixed to report. DO NOT mail transmittal form without report

attached.

_______

D. Annual Audited Financial Report with completed Transmittal Form E-AFR ................................................................. _________

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-RRG.AS (11/00)

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