Form E-Afr - Audited Financial Report Filing Transmittal 2010
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1DEPARTMENT OF INSURANCE
STATE OF ARIZONA
Reset
Financial Affairs Division - Compliance Section
th
2910 North 44
Street, Suite 210
Phoenix, Arizona 85018-7269
Phone: (602) 364-3245
Fax: (602) 364-3989
AUDITED FINANCIAL REPORT FILING TRANSMITTAL FORM - DUE
JUNE 1
GENERAL INSTRUCTIONS:
You are required to file, with us and the NAIC, an Audited Financial Report that has been prepared in
accordance with the requirements of ARS § 20-698 and the NAIC Annual Financial Reporting
Model Regulation.
THIS TRANSMITTAL FORM MUST BE COMPLETED AND ATTACHED TO THE COVER OF THE
REPORT FILED WITH US for identification and recording purposes.
Use our new Form E-AFR.IC transmittal form for your Communication of Internal Control Related
Matters Noted in an Audit filing, and for your Management’s Report of Internal Control Over Financial
Reporting filing, both of which are due
August
1.
SPECIAL INSTRUCTION FOR CONSOLIDATED REPORTS ONLY:
Each company in the group must separately file a copy of the consolidated audited financial
report with a Transmittal Form E-AFR to receive credit for the filing, because a copy of the
consolidated report must be retained in each Annual Statement filed with us.
•
ARIZONA DOMESTIC COMPANIES must attach a copy of the letter issued by us approving the
request to file on a consolidated basis.
•
FOREIGN COMPANIES must attach a copy of the letter issued by the state of domicile
approving the request to file on a consolidated basis.
A penalty fee of up to $25 per day may be assessed for any part of your annual audited financial
report that is filed late. ARS § 20-223.
IMPORTANT – ENTER THE CALENDAR YEAR OF THE ATTACHED REPORT:
REQUIRED FILING IDENTIFICATION AND RECORDING INFORMATION:
Enter the NAIC Number, name and domicile of the company whose individual Audited Financial
Report is attached, or on whose behalf a copy of a Consolidated Audited Financial Report is
attached.
NAIC NO.
COMPLETE COMPANY NAME
DOMICILE
PROVIDE THE INFORMATION BELOW FOR THE PERSON TO BE CONTACTED FOR ANY
QUESTIONS CONCERNING THIS REPORT:
Type or Print Name and Title
Phone (toll free, if available)
E-mail address:
E-AFR (Rev. 12/10)
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