Form E-Actuary - Attention - All Life Insurers, Fraternal Benefit Societies And Insurers Authorized To Reinsure Life Insurance, Annuities And Accident And Health Insurance In Arizona
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1Department of Insurance
State of Arizona
Financial Affairs Division
2910 North 44th Street, Suite 210
Phoenix, Arizona 85018-7256
Telephone: (602) 912-8420
Telecopier: (602) 912-8421
ATTENTION - ALL LIFE INSURERS, FRATERNAL BENEFIT SOCIETIES AND INSURERS AUTHORIZED TO
REINSURE LIFE INSURANCE, ANNUITIES AND ACCIDENT AND HEALTH INSURANCE IN ARIZONA
NOTICE OF ACTUARY APPOINTMENT OR RETENTION; A.R.S. § 20-696.02(D)
This form is provided to assist with compliance for required notification of actuary appointment or retention, as
prescribed by A.R.S. § 20-696.02(D) which became effective July 20, 1996.
Complete and return this form to the Financial Affairs Division, in care of this Department at the address shown
above.
Insurance Company Name
State of Domicile
NAIC Number
Actuary’s Complete Name
Title
If Consulting Actuary: Name of Firm
Business Address
City, State, Zip
Business Phone including Area Code
Date of Appointment or Retention
Check manner of Appointment or Retention: Board of Directors
, Executive Officer
, or
Other (specify):
CERTIFICATION STATEMENT ( To be executed jointly by an officer and the actuary)
I,
_______________________
as
the
________________________
and
I,
_______________________ as the appointed or retained actuary of the above named insurance
company, do hereby jointly submit this notification of actuary appointment in compliance with A.R.S. § 20-
696.02(D) and do further certify to compliance with the qualifications prescribed in A.R.S. § 20-696.02(B)
for such appointment.
Officer Signature:
Actuary Signature:
Date of Signature:
Date of Signature:
Form E-ACTUARY (06/00)
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