Arizona Policyholder And Certificate Census Sheet

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Return To: Maria G. Chavira
Arizona Department of Insurance
th
2910 N. 44
Street, Second Floor
Phoenix, AZ 85018-7256
ARIZONA POLICYHOLDER AND CERTIFICATE CENSUS
COMPANY NAME ______________________________________________ NAIC # ____________
___________________________________________
Signature and Title of Person Completing This Form
1
LIMITED BENEFIT PRODUCTS
(Provide total number of AZ insureds and/or certificate holders for each category)
Vision Only
Dental Only
Accident
AD & D
Disability
Hospital
Specified
Scheduled
Credit
Life
All Other Ltd.
Only
Income
Indemnity
Disease
Benefit
or Disability
Benefit Policies
4
Group
Individual
4
MAJOR MEDICAL PRODUCTS
(Provide total number of AZ insureds and/or certificate holders for each category)
2
3
Small Group (2-50)
Large Group (>50)
Individual Major Med.
Individual Short Term
All Other Major Medical
Association Group
Mass Marketed Group
VARIABLE PRODUCTS (Provide total number of AZ insureds and/or certificate holders for each category)
Individual Annuities
Group Annuities
Individual Life
Group Life
NON-VARIABLE (STANDARD) PRODUCTS (Provide total number of AZ insureds and/or certificate holders for each category)
Individual Annuities
Group Annuities
Individual Life
Group Life
SENIOR PRODUCTS (Provide total number of AZ insureds and/or certificate holders for each category)
4
4
Individual Medicare Supplement
Group Medicare Supplement
Individual Long Term & Home Health Care
Group Long Term & Home Health Care
Does your Company have an Internet address?
Yes
No
If yes, what is the address?
____________________________________________________
Does your Company transact the sale of insurance over the Internet either on its own website, or through a third party service (e.g., InsureMarket, Insweb, etc)? Yes
No
Does your Company write Major Medical coverage for Individuals as Association Members?
Yes
No
______________________________________
________________
________________________________________________________________________________
Name (Printed)
Phone Number
Address
City
State
Zip
1
Limited benefit products as defined by A.R.S. § 20-1137.
2
Bona fide Associations as defined by A.R.S. § 20-2324.
3
Mass marketed group health insurance as defined by A.R.S. § 20-1661.
4
Issued to Arizona residents under group policies whether it’s used in Arizona or not.

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