Form E-Afr.ohe - Audited Financial Report - Affidavit - 2015 Page 3
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AUDITED FINANCIAL REPORT
STANDARDIZED ORGANIZATIONAL HARDSHIP EXEMPTION
FOR ARIZONA DOMESTIC COMPANY ONLY
AFFIDAVIT
State of
)
) ss.
County of
)
I,
, being first duly sworn, upon my oath depose and say:
1.
I am the
of
,
whose NAIC number is _____ and am duly authorized to execute this affidavit on its behalf; and
2.
is
a
reinsurer
holding
a
certificate of authority in the State of Arizona only; and
3.
complies with the provisions of
items 4 through 7 of this affidavit with respect to each reinsurance contract and ceding insurer; and
4.
A trust account or custodial account is established with a qualified financial institution located
in the United States which is organized under the laws of the United States or any State of the United
States that has been granted authority to operate with Fiduciary power, in which assets equal to the net
reserve credit taken by the ceding insurer for the business ceded are deposited or, in the alternative, the
reinsurance agreement provides that funds will be withheld by the ceding insurer; and
5.
The trust account or custodial account requires only the ceding insurer's (direct writer's)
signature in order to withdraw funds and/or to pay claims, provided however, that with the approval of
the ceding insurer, funds may be withdrawn by the assuming reinsurer providing that, after the
withdrawal, the market value of assets in the trust account or custodial account shall be no less than
102 percent of the net reserves for the business ceded; and
6.
has obtained from the bank,
as custodian or trustee, a verification and listing of assets held in a trust or custodial account for the
purposes described in A.R.S. § 20-1092 as of the most recent calendar year end; and
7.
has not assumed gross
premiums of more than five million dollars in the ______ calendar year and is not otherwise required
to file an audited financial report on the basis of direct premiums.
Further affiant sayeth not.
Affiant Signature
Subscribed and sworn to before me this
day of
,
Stamp or seal
Notary Public Signature
My commission expires:
E-AFR.OHE (3/25/2015)
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