Form E-Title.dup - Title Insurer - Domestic Duplicate 2000 Annual Statement Filings Worksheet

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

Title Insurer – Domestic

DUPLICATE 2000 Annual Statement Filings Worksheet

NAIC: ____ Company : ______________________________________ Domicile: AZ

This Form must be completed and returned inside of the Duplicate Annual Statement that has been labeled “COPY” on its

front cover.

Enter the greater of policyholders or certificateholders of directly written

→

→

policies nationwide as of 12/31/00:→

MUST BE COMPLETED

Initial if

Initial at left if items are enclosed with 2000 Annual Statement

Agency

Enclosed

Use Only

↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓

↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓

_______ A.

ONE ENTIRE DUPLICATE of the 8-1/2” x 14” Hard Copy Annual Statement, including..................... ________

all bound pages and loose supplemental pages is required. This duplicate statement must be:

_______

1. Securely Bound and.................................................................................................................................. _ _ _ _ _ _

_______

2. Stamped “COPY” on the front cover ...................................................................................................... _ _ _ _ _ _

WHICH MUST INCLUDE TO BE COMPLETE:

3. Jurat Page Signatures (Properly executed as instructed in Form E-Title.AS Worksheet) ........................ ________

_______ B.

Actuarial Opinion OR ................................................................................................................................... ________

_______

1. Affidavit and copy of approval letter from this Department..................................................................... ________

THE FOLLOWING REPORTS MUST BE ATTACHED TO THIS WORKSHEET:

_______ C.

NAIC Annual Statement Diskette Transmittal Form OR .............................................................................. ________

_______

1. Annual Electronic Filing Transmittal Form and Certification (if filing with NAIC VIA INTERNET) ..... ________

_______ D.

SVO Compliance Certification ..................................................................................................................... ________

_______ E.

Form E-178 Certificate of Disclosure.................................................................................................................................. _________

WHICH MUST INCLUDE TO BE COMPLETE:

_______

1.

E-178, Part A must be answered yes or no (If yes, must have attachment) ................................................................. _ _ _ _ _ _ _

_______

2.

E-178, Part B must be answered yes or no (If yes, must have attachment) ................................................................. _ _ _ _ _ _ _

3.

E-178, Part D mus be answered yes or no (If yes, must have attachment) ................................................................. _ _ _ _ _ _ _

_______

4.

Two Executive Officer Original Signatures ................................................................................................................ _ _ _ _ _ _ _

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

_______

a.

Notary signature and stamp or seal...................................................................................................................... _ _ _ _ _ _ _

_______ F.

Management Discussion & Analysis with completed Transmittal Form E-MDA (if available and

enclosed)........................................................................................................................................................ ________

_______ G.

Annual Audited Financial Report with completed Transmittal Form E-AFR (if available and enclosed)... ________

PREPARED BY:

________________________________________________________________

____________________________________

Name & Title

Collect / Toll Free Phone Number

E-MAIL ADDRESS, if available:

E-TITLE.DUP (11/00)

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