Form E-Sl-Final - Arizona Licensed Surplus Lines Broker Final Statement And Premium Tax Report - 2005

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ARIZONA DEPARTMENT OF INSURANCE

Financial Affairs Division

COMPLIANCE SECTION

2910 NORTH 44TH STREET, SUITE 210

Phoenix, Arizona 85018-7269

Phone: (602) 912-8427 Fax: (602) 912-8421

ARIZONA LICENSED SURPLUS LINES BROKER FINAL STATEMENT AND PREMIUM TAX REPORT

FOR REPORTING PERIOD OF: _____________________ THROUGH ___________________

DATE OF SURPLUS LINES BROKER LICENSE TERMINATION: ________________________

DUE WITHIN 30 DAYS OF THE SURPLUS LINES LICENSE TERMINATION

READ FORM E-SL-FINAL.I

“FINAL STATEMENT AND PREMIUM TAX REPORT FILING INSTRUCTIONS BEFORE PROCEEDING

NSTRUCTION

TO PREPARE AND FILE THIS REPORT.

CHECK ONE:

Original report

Arizona License Number

Amended/Supplemental report

(SEE PG 2)

Name on License

Mailing Address

Telephone #:

FAX #

(

)

(

)

E-Mail Address:

PART B - AFFIDAVIT OF BROKER UNDER OATH

** This Final Affidavit must be executed and notarized to be considered a complete filing **

OATH

State of

}

County of

}

I ____________________________________________________________, being duly sworn, depose and say that I am now, or was

(Type or Print Complete Name of Affiant)

during the preceding six months, a duly licensed Arizona Surplus Lines Broker, or, I am duly authorized to execute this statement on behalf of the

licensed firm named below in my capacity as

(Title)

and that the information contained in Part A on Page 2 of this report, including any attachments thereto, is complete, true and correct to the best of

my knowledge and belief.

Type Name of Licensed Firm, if applicable:

Signature of Affiant Broker or Authorized

Official on behalf of a Licensed Firm

Subscribed and sworn to before me this _________ day of ________________________ , ________.

My commission expires:

(Notary Public)

SEAL

(

)

PAYMENT OPTIONS – CHECK ONE OPTION BELOW FOR PAYMENT OF THE TAX DUE (

PAGE 2, LINE 4)