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Department of Insurance

ATTENTION:

State of Arizona

ANNUAL STATEMENT PREPARER

Financial Affairs Division

THE NAME AND NAIC # OF INSURER MUST

2910 North 44th Street, Second Floor

BE ON ALL FORMS FILED WITH ADOI

Phoenix, Arizona 85018-7256

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

Property and/or Casualty, Mortgage Guaranty and Prepaid Legal Insurers - DOMESTIC

DUPLICATE 2000 Annual Statement Filings Worksheet

NAIC: _______ Company:_____________________________________

Domicile: AZ

This Form must be completed and returned inside the Duplicate Annual Statement that has been labeled

“COPY” on its front cover.

Enter the greater of policyholders or certificate holders of directly written policies nationwide as

→

of 12/31/00:→

MUST BE COMPLETED

Initial if

Initial at left if items are enclosed with 2000 Annual Statement

Agency

Enclosed

Use Only

↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓

_______ A.

ONE ENTIRE DUPLICATE of the 8-1/2” x 14” Hard Copy Annual Statement including all bound

_______

pages and loose supplemental pages is required. This duplicate statement must be: ................................. ________

_______

1. Securely Bound and.................................................................................................................................. ________

_______

2. Stamped “COPY” on the front cover. ..................................................................................................... ________

WHICH MUST INCLUDE TO BE COMPLETE:

_______

1. Jurat Page (Properly executed as instructed in Form E-170.AS Worksheet) ......................................... ________

_______

2. Copy of the Actuarial Opinion OR .......................................................................................................... ________

_______

a. Affidavit of Exemption ....................................................................................................................... ________

(Copy of the Insurance Director's Approval MUST accompany Affidavit)

_______

3. ARIZONA State Page 15 (Including all other states and Mexico, if applicable) ..................................... ________

COPY OF THE FOLLOWING REPORTS MUST BE ATTACHED TO THIS WORKSHEET:

_______ B.

NAIC Annual Statement Diskette Transmittal Form, OR ............................................................................. ________

_______

1. Annual Electronic Filing Transmittal Form and Certification (If filing with NAIC VIA INTERNET) ... ________

_______ C.

SVO Compliance Certification ...................................................................................................................... ________

_______ D.

Form E-PC.175 Supplement "B" to Schedule T - Arizona Only (If none, return stamped “NONE”).......... ________

_______ E.

Form E-178 Certificate of Disclosure............................................................................................................................. _________

WHICH MUST INCLUDE TO BE COMPLETE:

_______

Part A must be answered yes or no (If yes, must have attachment) .........................................................................

_______

Part B must be answered yes or no (If yes, must have attachment) .........................................................................

_______

Two Executive Officer Original Signatures ..........................................................................................................

(SIGNERS NAMES MUST BE LISTED ON THE 2000 JURAT PAGE)

_______

a. Notary signature and stamp or seal ...................................................................................................................

_______ F.

Form E-PC.350 Producer Controlled Property and Casualty Insurance....................................................... ________

_______ G.

Management Discussion & Analysis with attached Transmittal Form E-MDA........................................... ________

MORTGAGE GUARANTY INSURERS ONLY:

H. Form E-MG.MPP Mortgage Guaranty Insurers Report of Policyholders Position ........................................................... _________

_______

Supplementary Schedule F-5 Unauthorized Reinsurance MARKED “CONFIDENTIAL” (see instruction

Form E-MG.CEDE) .......................................................................................................................................................... _________

PREPARED BY:

________________________________________________________________

__________________________________

Name & Title

Collect / Toll Free Phone Number

E-PC.DUP (11/00)

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