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 85018-7286
Telephone: (602) 912-8420/Fax: (602) 912-8421
Risk Retention Group − − − − Foreign and Alien
2003 Annual Statement Filings Worksheet
Due March 1, 2004
NAIC #: ____
COMPANY: __________________________________________ DOMICILE: ____
Enter Company Figures Here
Enter Company Figures Here
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Assets:
AZ Direct Premiums:
(Page 2, Line 26, Col. 3)
(Page 110, Line 3, Col. 2)
Liabilities:
AZ Finances & Service Charges:
(Page 3, Line 26, Col. 1)
(Page 110, Line 3, Col. 8)
Common Capital:
AZ Purchasing Group Premiums:
(Page 3, Line 28, Col. 1)
(Page 110, Line 3, Col. 9)
Preferred Capital:
All Direct Premiums:
(Page 3, Line 29, Col. 1)
(Page 110, Line 58, Col. 2)
Policyholders Surplus:
All Finances & Service Charges:
(Page 3, Line 35, Col. 1)
(Page 110, Line 58, Col.8)
Reinsurance Assumed Affiliates:
Number of Policyholders Nationwide
(Page 8, Line 34, Col. 2)
as of 12/31/2003:
Reinsurance Assumed Non-Affiliates:
(Page 8, Line 34, Col. 3)
Initial if
Initial at left if items are enclosed with 2003 Annual Statement
Agency
Enclosed
Use Only
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_______
A. Annual Statement – 8-1/2" X 14" (YELLOW JACKET, SECURELY BOUND in two-sided book form) ...................... _________
INCLUDE, IF APPLICABLE:
_______
1.
Jurat Page .................................................................................................................................................................. _________
_______
a.
Two Authorized Notarized Signatures...............................................................................................................
(SIGNERS NAMES MUST BE LISTED ON THE 2003 JURAT PAGE)
_______
2.
Actuarial Opinion or.................................................................................................................................................. _________
_______
a.
Affidavit of Exemption (Copy of Domiciliary Commissioner Approval MUST accompany Affidavit) ........... _________
IF THE FOLLOWING REPORTS ARE AVAILABLE, PLEASE ATTACH TO THIS WORKSHEET:
_______
B.
Management Discussion & Analysis with completed Transmittal Form E-MDA ........................................................... _________
The transmittal form MUST be completed and affixed to report. DO NOT mail transmittal form without report
attached.
_______
C.
Annual Audited Financial Report with completed Transmittal Form E-AFR ................................................................. _________
The transmittal form MUST be completed and affixed to report. DO NOT mail transmittal form without report
attached.
PREPARED BY:
_____________________________________________
_____________________________
Name & Title
Collect / Toll Free Phone Number
E-MAIL Address
E-RRG.AS (11/03)
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