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DEPARTMENT OF INSURANCE
CERTIFICATION STATEMENT
STATE OF ARIZONA
OF INDUSTRIAL INSURED CONTRACTING WITH
Financial Affairs Division- Tax Unit
th
2910 North 44
Street, Suite 210
UNAUTHORIZED INSURER(S)
Phoenix, Arizona 85018-7269
Phone: (602) 364-3246
CALENDAR YEAR _____________
Fax: (602) 364-3989
TO BE ATTACHED TO ARIZONA PREMIUM RECEIPTS TAX RETURN FORM E-INDINS.TAX
CERTIFICATION FOR CONTRACTS WITH UNAUTHORIZED INSURERS IN CALENDAR YEAR:
Complete Name of Insured: __________________________________________________________________
Insured’s Principal Address: _________________________________________________________________
Preparer’s Name and Title: __________________________________________________________________
Telephone Number: ____________________________ E-Mail Address: _____________________________
SEE FORM E-INDINS.INSTRUCTION FOR DEFINITIONS OF INDUSTRIAL INSURED AND RISK MANAGER FOR
PURPOSES OF COMPLETING THIS CERTIFICATION STATEMENT.
PART 1
A.
Provide the following information applicable to the Insured’s Risk Manager:
Full Name
i.
ii.
Degrees and/or designations held are:
iii.
If an Employee, his/her Title is:
B.
Specify a Yes or No Response to each question.
Yes
No
Did the Insured’s annual aggregate gross premiums for insurance on all Property and
i.
Casualty risks subject to Article 4.1, Chapter 2 of ARS Title 20 equal $100,000 or more as of
the insured’s preceding fiscal year end?
ii.
Did the Insured possess a net worth of $10 million or more as of its preceding fiscal year end
as verified by a Certified Public Accountant?
iii.
Did the Insured’s net revenues or sales exceed $25 million as of the preceding fiscal year
end as verified by a Certified Public Accountant?
Did the Insured have more than 80 full-time employees or equivalent on the date the policy
iv.
was issued or did the Insured's holding company system have 100 full-time employees or
equivalent on the date the policy was issued?
If 2 or more responses to Part 1.B. are YES, disregard Part 2, but sign and date this form on Page 2
ARIZONA DEPARTMENT OF INSURANCE
E-INDINS.C
(R
. 12/09)
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