Form E-Indins.cd - Industrial Insured Certification Statement - Department Of Insurance State Of Arizona

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DEPARTMENT OF INSURANCE

STATE OF ARIZONA

FINANCIAL AFFAIRS DIVISION - COMPLIANCE SECTION

2910 North 44

Street, Suite 210

Phoenix, Arizona 85018-7256

Phone: (602) 912-8427 Fax: (602) 912-8421

INDUSTRIAL INSURED CERTIFICATION STATEMENT

TO BE ATTACHED TO ARIZONA PREMIUM RECEIPTS TAX RETURN FORM E-INDINS.TAX

CALENDAR YEAR PERIOD FOR THIS CERTIFICATION:

Complete Name of Insured:________________________________________________________________________________________________

Insured’s Principal Address: _______________________________________________________________________________________________

Preparer’s Name and Title: __________________________________________________

_________________________________________

Telephone Number: _______

E-Mail Address:

_______________________________________________

PART 1 - To be completed by ALL Industrial Insureds that procured, renewed or continued coverage(s) from an unauthorized insurer for

risks or exposures wholly or partly located in Arizona.

Provide the information for A and B below, that is applicable to the Insured’s Risk Manager, as defined in A.R.S. § 20-401.07(B)(2):

Name of Risk Manager (see Page 1 of Form E-INDINS.I

)

NSTRUCTION

Degrees or designations held

Annual aggregate gross premiums for insurance on all Property and Casualty risks subject to Article 4.1,

Chapter 2 of A.R.S. Title 20 as of the preceding fiscal year end of the Industrial Insured.

The Insured’s net worth as of its preceding fiscal year end as verified by a Certified Public Accountant.

The Insured’s net revenues or sales as of the preceding fiscal year end as verified by a Certified Public

Accountant.

Number of full-time employees or equivalent of Insured as of the date the policy was issued.

Number of full-time employees or equivalent of Insured’s holding company system as of the date the policy

was issued.

PART 2 - To be completed only by Insureds claiming exemption from the definition of Industrial Insured under the qualifying criteria.

INITIAL EACH of the following statements:

_____ The Insured does not meet the definition and qualifying criteria of Industrial Insured prescribed in A.R.S. § 20-401.07 for this period.

_____ The Insured does not owe any premium receipts tax to the State of Arizona Department of Insurance for this period.

_____ The Insured acknowledges its responsibility to contact the Arizona Department of Insurance at any time in the future to certify that it meets, or

is exempt from, the definition of Industrial Insured for its future transactions with Unauthorized Insurers, or at any time that the Department

may request such information for its records.

PREPARER’S CERTIFICATION

I hereby certify that I am authorized by the named Insured to prepare this Statement on its behalf and it is true and correct to the best of

my information, knowledge and belief.

Signature ____________________________________________________________

Date ______________________________________

E-INDINS.C

. 12/04)

ERTIFICATION

AGE