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Form E-Pc.indins - Report Of Policies Issued To Industrial Insureds - Department Of Insurance Of State Of Arizona

Department of Insurance

State of Arizona

Financial Affairs Division

2910 North 44th Street, Second Floor

Phoenix, Arizona 85018-7256

Telephone: (602) 912-8420/Fax: (602) 912-8421

REPORT OF POLICIES ISSUED TO INDUSTRIAL INSUREDS

Company Name

NAIC Number

Domicile

Pursuant to the amendments to A.R.S. § 20-400.10 enacted in Senate Bill 1069 and effective July 18, 2000, each insurer that issues a

policy to an Industrial Insured, as defined in A.R.S. § 20-401.07, SHALL include with its Annual Statement filed with this Department

pursuant to A.R.S. § 20-223, the information below for all policies issued to Industrial Insureds for the calendar year period.

The following information is reported in accordance with A.R.S. § 20-400.10(F) for policies issued by the

insurer named above to Industrial Insureds:

1. The Total Number Of Policies Written.

2. The Total Premiums Written.

3. The Total Premiums Earned.

4. The Total Losses Paid.

5. The Total Losses Incurred.

6. The Total Number Of Claims Incurred.

PREPARED BY:

______________________________________________________________________

______________________________________

Name & Title

Collect / Toll Free Phone Number

E-MAIL ADDRESS, if available:

E-PC.INDINS (12/00)

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Form E-Pc.indins - Report Of Policies Issued To Industrial Insureds - Department Of Insurance Of State Of Arizona