Form Ld-T - Annual Report Of Premiums,taxes And Fees Of Foreign Life And Accident And Health Insurance Companies - 2011 Page 9

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NAIC_________ COMPANY NAME________________________________ 2011 FORM AID AC LD-T
CHECKLIST
Copy of Schedule T of Annual Statement attached?…………………………… ___ YES
___ NO
Copy of AR Direct Business from Annual Statement attached?……………. ___ YES
___ NO
Copy of Jurat page from Annual Statement attached?……………………….. ___ YES
___ NO
Completed Schedule ICPT for Salary Credit?…………………………………….. ___ YES
___ NO
Attached check payable to State Treasurer of Arkansas?………………
___ YES
___ NO
Signed and Notarized return?………………………………………………………….
___ YES
___ NO
AFFIDAVIT
State of ______________________________________________
County of _____________________________________________
Comes _____________________________________________________________________and states on oath that he/she is the
_______________________________________ of____________________________________________________________________
(Title)
(Name of Company)
and that the foregoing statements are true and correct as shown by the records of said Company.
__________________________________________________
(ORIGINAL SIGNATURE OF OFFICER)
Subscribed and sworn to or affirmed before me, the undersigned Notary Public, on this the ______ day of_______ , 20______
————————————————————————–
NOTARY PUBLIC
My Commission Expires _________________________________
FOR Insurance Department Use Only:
Verified by:________________ RT Slip #___________________ Check#_______________ Amount___________________
ARKANSAS INSURANCE DEPARTMENT
Page 4 of 4
REVISED 2011
FEDERAL TAX ID NUMBER 71-0847443

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