Fillable ANNUAL STATEMENT WORKSHEET FOR DOMESTIC MECHANICAL REIMBURSEMENT REINSURER (Arizona)

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ANNUAL STATEMENT WORKSHEET FOR DOMESTIC MECHANICAL REIMBURSEMENT REINSURER (Arizona)

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E-MRR.AS (v 20201031)
ANNUAL STATEMENT WORKSHEET FOR
DOMESTIC MECHANICAL REIMBURSEMENT REINSURER
ENTER THE CALENDAR YEAR FOR THIS ANNUAL STATEMENT WORKSHEET:
COMPANY:
NAIC#:
DOMICILE:
AZ
THIS WORKSHEET AND THE ANNUAL STATEMENT ARE DUE APRIL 1
Initial if
Included
↓
↓
↓
Initial at left for each item included with Annual Statement
Use
Only
A. Annual Statement – 8-1/2” X 14”
MUST INCLUDE THE FOLLOWING TO BE COMPLETE:
1. Jurat Page
a. TWO executive officer signatures (Names must be on Jurat Page)
b. Notary signature and stamp or seal
2. Actuarial Opinion or Enter N/A in box if your Affidavit of Exemption and a copy
of our letter granting the exemption are enclos
ed
B. Form E-MRR.05 Annual Report of Policy and Loss Reserves and Application for
Certificate of Authority Renewal
C. Management Discussion & Analysis (due April 1)
D. IF AVAILABLE, Audited Financial Report (due June 1)
SEND SEPARATELY TO THE INSURANCE FINANCIAL AFFAIRS
DIVISION:
Annual Insurance Holding Company System Registration Statement
Form B, C, and F (due March 31)
PREPARED BY:
Name and Title
Phone Number
Email address
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ANNUAL STATEMENT WORKSHEET FOR DOMESTIC MECHANICAL REIMBURSEMENT REINSURER (Arizona)

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Completed 1 July 2022

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