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2003 ANNUAL STATEMENT WORKSHEET FOR ALL FOREIGN AND ALIEN

INSURERS and ACCREDITED REINSURERS

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Certificate of Compliance.................................................................................................................................

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Certificate of Deposit........................................................................................................................................

SECTION III: NOT APPLICABLE TO ACCREDITED REINSURERS. ADDITIONAL REQUIREMENTS APPLICABLE TO

EACH SPECIFIED COMPANY TYPE. INITIAL AT LEFT OF EACH ITEM COMPLETED AND ENCLOSED

Initial if

AGENCY

Enclosed

Use Only

↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓

LIFE AND/OR DISABILITY INSURER

(Annual Statement Blue Jacket):

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Arizona State Page 30....................................................................................................................................... ________

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Life Insurers Only: Certificate of Valuation (If Disability Insurer only enter N/A in box→

..........

PROPERTY AND/OR CASUALTY INSURER

(Annual Statement Yellow Jacket):

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If applicable: Actuarial Opinion Exemption Affidavit & copy of Domiciliary Commissioner Approval ........ ________

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Arizona State Page 26 ...................................................................................................................................... ________

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Form E-PC.INDINS ........................................................................................................................................

MORTGAGE GUARANTY INSURER (Only)

(Annual Statement Yellow Jacket):

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If applicable: Actuarial Opinion Exemption Affidavit & copy of Domiciliary Commissioner Approval ....... ________

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Arizona State Page 26 ...................................................................................................................................... ________

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Form E-MG.MPP Mortgage Guaranty Insurers Report of Policyholders Position........................................... ________

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Supplementary Schedule F-5 Unauthorized Reinsurance MARKED “CONFIDENTIAL”

(See instruction Form E-MG.CEDE)................................................................................................................ ________

PREPAID LEGAL INSURER (Only)

(Annual Statement Yellow Jacket):

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Arizona State Page 26 ...................................................................................................................................... ________

TITLE INSURER

(Annual Statement Salmon Jacket):

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If applicable: Actuarial Opinion Exemption Affidavit & copy of Domiciliary Commissioner Approval ........ ________

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Form E-AGENT-LIST ..................................................................................................................................... ________

FRATERNAL BENEFIT SOCIETY

(Annual Statement Brown Jacket):

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Arizona State Page 29....................................................................................................................................... ________

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Certificate of Valuation ...................................................................................................................................

PREPARED BY: (must complete)

Name and Title

Collect/Toll Free Phone Number

E-MAIL address

E-WORKSHEET.FOREIGN (01/04)

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