Form E-Indins - Certification Statement Of Industrial Insured Contracting With Unauthorized Insurer(S) - 2009 Page 2

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CERTIFICATION STATEMENT OF INDUSTRIAL INSURED CONTRACTING WITH UNAUTHORIZED
INSURER(S)
PART 2 - To be completed only by Insured’s with only 1 or no YES response entered in Part 1 B.
Do you claim to be exempt from the definition of Industrial Insured prescribed in ARS § 20-401.07(B)?
A.
Yes
No
If Yes, provide the following information:
Identify all risk(s) insured, other than life disability and annuity contracts and the insurer of each risk. Attach a list
i.
in identical format, if needed.
Risk(s)
Complete Insurer Name(s)
ii.
Name, title and functions of the full-time employee acting as an insurance manager or buyer or the name, address
and functions of the Insured’s regularly and continuously retained qualified insurance consultant (i.e., Risk
Manager).
iii. Total aggregate annual premiums of the Insured.
$
iv. Total number of full-time employees of the Insured.
v. Any additional information for consideration:
PREPARER’S CERTIFICATION
I hereby certify that I am authorized by the named Insured to prepare this Statement on its behalf and it
is true and correct to the best of my information, knowledge and belief.
Signature _______________________________________________
Date ______________________
Attach both pages of this document to Premium Receipts Tax Return Form E-IND.INS
ARIZONA DEPARTMENT OF INSURANCE
E-INDINS.C
(R
. 12/09)
P
2
2
ERTIFICATION
EV
AGE
OF

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