E-LR.AS (v 20210225)
ANNUAL STATEMENT WORKSHEET FOR
DOMESTIC LIFE AND DISABILITY REINSURER
ENTER THE CALENDAR YEAR FOR THIS ANNUAL STATEMENT WORKSHEET:
THIS WORKSHEET AND THE ANNUAL STATEMENT ARE DUE MARCH 31
if
Filed
Initial at left for each item included with the filing
Use
Only
A. Annual Statement – 8-1/2” X 14”
MUST BE FILED ELECTRONICALLY and INCLUDE THE FOLLOWING TO BE
COMPLETE:
1. Jurat Page
a. TWO executive officer (Names must be listed on Jurat Page)
b. Notary signature and stamp or seal
2. Actuarial Opinion (Enter N/A in box if premiums and reserves = Zero
3. Life Risk Based Capital Report
B. Form E-178 Certificate of Disclosure
MUST BE FILED ELECTRONICALLY and INCLUDE THE FOLLOWING TO BE
COMPLETE:
1. Part A must be answered yes or no (If yes, must have attachment)
2. Part B must be answered yes or no (If yes, must have attachment)
3. TWO executive officer electronic signatures (Names must be on Jurat Page)
C. Management Discussion & Analysis (due April 1)
D. IF AVAILABLE, Audited Financial Report
Annual Insurance Holding Company System Registration Statement Form B, C, and F (due March 31)
Send completed form(s) to financialfilings@difi.az.gov
. DO NOT send a hard copy.
FEE PAYMENT (due March 31)
Remit the $4,800 (consisting of $300 for Payment Type 28 and $4,500 for Payment Type 57) fee payment using
NAIC OPTins (www.optins.org) or by sending a check made payable to the Arizona Department of Insurance
and Financial Institutions along with a copy of this Annual Statement Worksheet Form E-LR.AS to the
Department.
PREPARED BY:
