Form E-Pc.as-Annual Statement Filings Worksheet November 2000 Page 2

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

Property and/or Casualty, Mortgage Guaranty and Prepaid Legal Insurers

Domestic, Foreign and Alien

2000 Annual Statement Filings Worksheet

NAIC:

COMPANY: ___________________________________ DOMICILE: ___

Initial if

Agency

Enclosed

Initial at left if items are enclosed with 2000 Annual Statement

Use Only

↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓

↓ ↓ ↓ ↓ .................................................................................................................................................................................... ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓

SECTION II: DOMESTIC INSURERS 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 stamped "COPY" on the front page. You must

enclose the Duplicate Annual Statement Filings Worksheet Form E-PC.DUP in your duplicate filing ............................ _________

THE FOLLOWING REPORTS MUST BE ATTACHED TO THIS WORKSHEET:

_______

B.

Copy of NAIC Annual Statement Diskette Transmittal Form, OR ..................................................................................... _________

_______

1.

Annual Electronic Filing Transmittal Form and Certification (If filing with NAIC VIA INTERNET) ...................... _________

_______

C.

Copy of SVO Compliance Certification.............................................................................................................................. _________

D. Property / Casualty Risk Based Capital Report (Hard copy) OR ........................................................................................ _________

_______

_______

1.

Copy of Department’s approval of exemption.............................................................................................................

_______

E.

Form E-PC.350 Producer Controlled Property and Casualty Insurance ............................................................................ _________

INITIAL TO CONFIRM THAT THE FOLLOWING REPORTS HAVE BEEN OR WILL BE SENT UNDER SEPARATE

MAILING TO ATTENTION: COMPLIANCE SECTION. DO NOT MAIL IN ANNUAL STATEMENT ENVELOPE.

_______

F.

Annual Insurance Holding Company System Registration Statement Forms B and C........................................................ _________

PREPARED BY:

______________________________________________________________________

_______________________________________

Name & Title

Collect / Toll Free Phone Number

E-MAIL ADDRESS, if available:

E-PC.AS (11/00)

Page 2 of 2