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100 North 15 Avenue, Suite 261 Phoenix, Arizona (Arizona)

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100 North 15
th
Avenue, Suite 261
Phoenix, Arizona 85007-2630
Phone: (602) 364-4490
Web: https://difi.az.gov/
CAPTIVE INSURER ANNUAL REPORT AND RENEWAL FEE TRANSMITTAL - RRGs
File the annual report and most related filings using the NAIC online system or the Captive Insurer filing portal as instructed.
CID-AnnRepTrans RRG 01 2021
INFORMATION ABOUT THE RISK RETENTION GROUP
Company Name
NAIC #
Home Office Street Address
City
State
ZIP Code
On what date each year does the insurer’s
fiscal year end? ►
Month
INFORMATION ABOUT THE PREPARER
Preparer’s Name
Title
Area Code & Phone Number
Preparer’s Email Address
Fax Number
Preparer’s Mailing Address
City
State
ZIP Code
REQUIREMENTS CHECKLIST (submit payment by mail or electronically through the portal; submit all other
documents not filed directly with the NAIC through the AZ DIFI filing portal unless noted otherwise below)
☐
$5,500.00 (Pay Code 87) Certificate of Authority Renewal Fee
●Make check payable to Arizona Department of Insurance and Financial Institutions.
●Write the license/NAIC number in the memo section of the payment or the payment stub.
●Mail payment to the address at the top of this form. Payment may also be made via e-check or credit card
through the Captive Insurer Annual Report web portal.
☐
RRG Annual Statement, submitted electronically directly to the NAIC
☐
RRG Annual Statement Jurat Page, signed by two officers of the captive insurer and the
captive manager, submitted via the portal (also applicable for quarterly filings)
☐ Risk Based Capital Report, submitted electronically to the NAIC
☐ Actuarial Opinion, submitted electronically to the NAIC, unless exempt or waived ☐
☐
Actuarial Opinion Summary, submitted via the portal, unless exempt or waived
☐
☐ Management Discussion and Analysis, submitted electronically to the NAIC
☐ Form E-178: Certificate of Disclosure, submitted via the portal
☐ Annual audited financial report, submitted to the NAIC, unless exempt or waived ☐
☐ Holding Company filings if applicable (e.g. Form B, C, F, etc.), submitted via e-mail to
financialfilings@difi.az.gov
☐ Annual disclosure regarding RRG Board independence (A.R.S. 20-2402.C.2)
IMPORTANT: Any risk retention group failing to file its annual report or pay its annual renewal fee on or before the due
date is subject to financial penalties and suspension of its Arizona Certificate of Authority pursuant to A.R.S. §20-1098.07
.
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100 North 15 Avenue, Suite 261 Phoenix, Arizona (Arizona)

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Completed 1 July 2022

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