Form E-Arpc.as - Accredited Property/casualty Reinsurer - Foreign And Alien - Annual Statement Filings Worksheet - 2000

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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
Accredited Property/Casualty Reinsurer - Foreign and Alien
2000 Annual Statement Filings Worksheet
NAIC: ___ COMPANY: ____________________________________ DOMICILE: ___
Initial if
Initial at left if items are enclosed with 2000 Annual Statement
Agency
Enclosed
Use Only
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_______
A.
Annual Statement - 8-1/2” X 14” (YELLOW JACKET, SECURELY BOUND in two-sided book form)................... _________
WHICH MUST INCLUDE TO BE COMPLETE:
_______
1. Jurat Page ................................................................................................................................................................
_______
a. Two Authorized Notarized Signatures...............................................................................................................
(SIGNERS NAMES MUST BE LISTED ON THE 2000 JURAT PAGE)
_______
2. Actuarial Opinion ....................................................................................................................................................
THE FOLLOWING REPORTS MUST BE ATTACHED TO THIS WORKSHEET:
_______
B.
Form E-178 Certificate of Disclosure............................................................................................................................ _________
WHICH MUST INCLUDE TO BE COMPLETE:
_______
1. E-178, Part A must be answered yes or no (If yes, must have attachment) .............................................................
_______
2. E-178, Part B must be answered yes or no (If yes, must have attachment) .............................................................
_______
3. Two Executive Officer Original Signatures.............................................................................................................
(SIGNERS NAMES MUST BE LISTED ON THE 2000 JURAT PAGE)
_______
a. Notary signature and stamp or seal....................................................................................................................
IF THE FOLLOWING REPORTS ARE AVAILABLE, PLEASE ATTACH TO THIS WORKSHEET:
_______
C.
Management Discussion & Analysis with Transmittal Form E-MDA.......................................................................... _________
The transmittal form MUST be completed and affixed to report. DO NOT mail transmittal form without
report attached.
_______
D.
Annual Audited Financial Report with Transmittal Form E-AFR ................................................................................ _________
The transmittal form MUST be completed and affixed to report. DO NOT mail transmittal form without
report attached.
PREPARED BY:
______________________________________________________________________
_______________________________________
Name & Title
Collect / Toll Free Phone Number
E-MAIL address, if available:
E-ARPC.AS (11/00)
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