E-UCLDR.AS (v 20210316)
ANNUAL STATEMENT WORKSHEET FOR
DOMESTIC UNAFFILIATED CREDIT LIFE AND DISABILITY REINSURER
ENTER THE CALENDAR YEAR FOR THIS ANNUAL STATEMENT WORKSHEET:
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 signatures (Names must be listed on Jurat Page)
b. Notary signature and stamp or seal
THE FOLLOWING REPORTS MUST BE INCLUDED WITH THE FILING:
B. Form E-UCLDR.CERT Annual Certification and Affidavit of Verification
MUST INCLUDE TO BE COMPLETE:
1. Signatures of President & Secretary or provide a Corporate Resolution of
Authorization for signers other than President & Secretary
2. Notary signature and stamp or seal
C. Copy of Financial Institution Statement of Trust Deposit and/or a copy of Letter(s) of
Credit that secure reserves as required by ARS § 20-1094.01. If funds are withheld
by ceding insurers, provide a copy of the cession statement(s) disclosing the
amount of funds withheld
D. 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)
FEE PAYMENT (Due August 1 of November 1, as applicable)
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-UCLDR.AS to the
Department.
PREPARED BY:
