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Form E-Sl-1 - Az Surplus Lines Broker - Semi-Annual Statement And Premium Tax Report - 2003

ARIZONA DEPARTMENT OF INSURANCE

PREMIUM TAX UNIT

DUE ON OR BEFORE SEPTEMBER 1, 2003

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

ARIZONA SURPLUS LINES BROKER

SEMI-ANNUAL STATEMENT AND PREMIUM TAX REPORT - January 1, 2003 through June 30, 2003

READ FORM E-SL-1.I

“2003 ARIZONA SURPLUS LINES BROKER SEMI-ANNUAL STATEMENT AND PREMIUM TAX REPORT FILING

NSTRUCTION

INSTRUCTIONS” BEFORE PROCEEDING TO PREPARE AND FILE THIS REPORT.

Arizona License Number

Name on License

Mailing Address

Telephone # (

)

FAX #

(

)

E-Mail Address:

PART B - AFFIDAVIT OF BROKER UNDER OATH

** This Semi-Annual Statement must be executed and notarized to be considered a complete filing **

OATH

State of

} ss

County of

}

I ____________________________________________________________, being duly sworn, depose and say that I am now, or was

(Type or Print Complete Name of Affiant)

during the preceding six months, a duly licensed Arizona Surplus Lines Broker, or, I am duly authorized to execute this statement on behalf of the licensed corporation named

below in my capacity as

(Title)

and that the information contained in Part A on Page 2 of this report, including any attachments thereto, is complete, true and correct to the best of my knowledge and belief.

(Type Name of Licensed Corporation, if applicable)

Signature of Affiant Broker or Authorized

Official on behalf of a Licensed Corporation

Subscribed and sworn to before me this _________ day of ________________________ , Year_______.

My commission expires:

(Notary Public)

(SEAL)

To assist in cross-referencing and reconciling our records, please provide the names and Arizona

license numbers of other individuals or corporations licensed as Arizona Surplus Lines Brokers

whose activity and reporting for any part of the preceding six months may be related to your surplus

lines activity and reporting.

E-SL-1 (R