Form E-Qrtpc.as - Property/casualty Qualified Reinsurer Trust Pursuant To A.r.s. 20-261.01(A)(4) Foreign And Alien 2000 Annual Statement Filings Worksheet

Department of Insurance

ATTENTION:

ANNUAL STATEMENT PREPARER

State of Arizona

THE NAME AND ARIZONA CODE # OF INSURER

Financial Affairs Division

2910 North 44th Street, Second Floor

MUST BE ON ALL FORMS FILED WITH ADOI

Phoenix, Arizona 85018-7256

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

Property/Casualty Qualified Reinsurer Trust Pursuant to A.R.S. § 20-261.01(A)(4)

Foreign and Alien

2000 Annual Statement Filings Worksheet

AZ Code #: _______

COMPANY: ______________________________________

DOMICILE: ____

Property & Casualty (Yellow) Book Instructions

Enter Company Figures Here

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Assets:

(Page 2, Line 22, Col. 4)

Liabilities:

(Page 3, Line 23, Col. 1)

Policyholders Surplus:

(Page 3, Line 27, Col. 1)

Reinsurance Assumed Affiliates:

(Page 9, Line 32, Col. 2a)

Reinsurance Assumed Non-Affiliates:

(Page 9, Line 32, Col. 2b)

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) ..................... _________

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.

Trust Statements................................................................................................................................................................ _________

** _____

C.

Underwriter Solvency Certifications Accredited Reinsurer Groups only.-(see Form EQTRPC.I, Item 5)

** if not applicable, Enter “N/A” in box →

............................................................................................... _________

PREPARED BY:

__________________________________________________________________

___________________________________________

Name & Title

Collect / Toll Free Phone Number

E-MAIL ADDRESS, if available:

E-QRTPC.AS (11/00)

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