Form E-Afr - Audited Financial Report Filing Transmittal Form May 2003
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1Department of Insurance
ATTENTION:
State of Arizona
This Transmittal Form MUST be completed and
Financial Affairs Division
2910 North 44th Street, Second Floor
attached to the Report prior to mailing.
Phoenix, Arizona 85018-7256
Telephone: (602) 912-8420/Fax: (602) 912-8421
2003 AUDITED FINANCIAL REPORT FILING TRANSMITTAL FORM DUE JUNE 1
GENERAL INSTRUCTIONS:
All insurers are required to file an Audited Financial Report that has been prepared in accordance with the current NAIC
Annual Statement Instructions, with this Department and with the NAIC. THIS TRANSMITTAL FORM MUST BE
COMPLETED AND ATTACHED TO THE COVER OF THE FILING MADE WITH THIS DEPARTMENT for
identification and recording purposes.
SPECIAL INSTRUCTION FOR CONSOLIDATED FILINGS ONLY:
Each company authorized in Arizona must submit a copy of the consolidated audited financial report with a
Transmittal Form E-AFR to receive credit for the filing, because a copy must be retained in each Annual Statement
filed with this Department.
•
ARIZONA DOMESTIC INSURERS must attach a copy of the letter issued by this Department approving the
request to file on a consolidated basis.
•
FOREIGN INSURERS must attach a copy of the letter issued by their state of domicile approving the request to file
on a consolidated basis.
1. REQUIRED FILING IDENTIFICATION AND RECORDING INFORMATION:
Provide the NAIC Number, name and domicile of the authorized insurance company whose individual Audited
Financial Report is attached, or on whose behalf this copy of a Consolidated Audited Financial Report is attached.
NAIC NO.
COMPLETE COMPANY NAME
DOMICILE
2. REQUIRED FINANCIAL INFORMATION:
Enter the Capital/Surplus amount from the Audited Financial Report that is APPLICABLE TO THE
COMPANY IDENTIFIED IN #1 ONLY (not the consolidated amount for all companies) in the space below.
DO NOT ENTER AN AMOUNT THAT IS ROUNDED TO THOUSANDS OR MILLIONS
•
If the Audited Financial Report figures are rounded to Thousands, ADD 3 zeros for the entry below.
•
If the Audited Financial Report figures are rounded to Millions, ADD 6 zeros for the entry below.
CAPITAL/SURPLUS: $
___
PROVIDE THE COMPLETE NAME, TITLE, DATE AND (COLLECT OR TOLL FREE) TELEPHONE NUMBER OF
THE PERSON TO BE CONTACTED FOR QUESTIONS CONCERNING THIS FILING:
Type or print name and title
Phone, toll free # , if available
E-MAIL ADDRESS (if available):
E-AFR (REV. 05/03)
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