Form E-Arld.as - Accredited Life/disability Reinsurer (Foreign And Alien) - Annual Statement Filings Worksheet - 2000

ADVERTISEMENT

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 Life/Disability 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
↓ ↓ ↓ ↓
↓ ↓ ↓ ↓
↓ ↓ ↓ ↓
↓ ↓ ↓ ↓
↓ ↓ ↓ ↓
↓ ↓ ↓ ↓
_______
A. Annual Statement - 8-1/2” X 14” (BLUE 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.
Form E-178 Certificate of Disclosure................................................................................................................................ _________
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:
Management Discussion & Analysis with completed Transmittal Form E-MDA ............................................................ _________
_______
C.
The transmittal form MUST be completed and affixed to report. DO NOT mail transmittal form without
report attached.
_______
D. Annual Audited Financial Report with completed 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-ARLD.AS (11/00)
Page 1 of 1

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go