Annual Statement Worksheet For Foreign And Alien Insurers And Accredited Reinsurers - Arizona Department Of Insurance - 2003
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1
2Department of Insurance
State of Arizona
Financial Affairs Division
2910 North 44th Street, Second Floor
Phoenix, Arizona 85018-7256
Telephone: (602) 912-8420/Fax: (602) 912-8421
2003 ANNUAL STATEMENT WORKSHEET FOR FOREIGN AND ALIEN
INSURERS and ACCREDITED REINSURERS
Not applicable to Foreign/Alien Risk Retention Groups or Insurers filing Health Annual Statement
COMPANY:____________________________________________________________
NAIC#:
DOMICILE:
CHECK ONE TYPE:
Life and/or Disability Insurer*
Fraternal Benefit Society
Property and/or Casualty Insurer*
Prepaid Legal Insurer (only)
Mortgage Guaranty Insurer (only)
Accredited Life/Disability Reinsurer
Title Insurer
Accredited Property/Casualty Reinsurer
*NOTE: Insurers filing the Health Annual Statement must use Form E-WORKSHEET.HEALTH
SECTION I: REQUIREMENTS APPLICABLE TO ALL COMPANY TYPES LISTED ABOVE. INITIAL AT LEFT OF
EACH ITEM COMPLETED AND ENCLOSED
Initial if Completed
AGENCY
And Enclosed
Use Only
↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓
↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓
______
A.
Annual Statement – 8-1/2” X 14” (Securely Bound in two-sided book form) ................................................. ________
(See Section II for Annual Statement jacket color applicable to each company type)
MUST INCLUDE THE FOLLOWING TO BE COMPLETE:
______
1. Jurat Page.................................................................................................................................................... ________
______
a.
TWO Executive Officer Signatures (Signers Names Must be listed on 2003 Jurat Page)................
______
b.
Notary signature and stamp or seal.....................................................................................................
Actuarial Opinion NOTE: If Reserves = ZERO MUST ENTER N/A in box → → → →
______
2.
.................... ________
See Section II instructions if an exemption has been granted.
______
B.
Management Discussion & Analysis with completed Transmittal Form E-MDA (due April 1) ..................... ________
(Transmittal form MUST be completed and affixed to report.)
______
C.
If available, Audited Financial Report with completed Transmittal Form E-AFR (due June 1)......................
(Transmittal form MUST be completed and affixed to report.)
SECTION II: NOT APPLICABLE TO ACCREDITED REINSURERS. ADDITIONAL REQUIREMENTS APPLICABLE TO ALL
OTHER COMPANY TYPES LISTED ABOVE. INITIAL AT LEFT OF EACH ITEM COMPLETED AND ENCLOSED
Initial if Completed
AGENCY
And Enclosed
Use Only
↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓
↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓
______
D.
Form E-178 Certificate of Disclosure............................................................................................................... ________
MUST INCLUDE THE FOLLOWING TO BE COMPLETE:
______
1.
Part A must be answered yes or no (If yes, must have attachment)...........................................................
______
2.
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 2003 Jurat Page)..........
______
a.
Notary signature and stamp or seal.....................................................................................................
______
4.
Title Insurers Only: Part D must be answered yes or no ...........................................................................
E-WORKSHEET.FOREIGN (01/04)
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