ARIZONA DEPARTMENT OF INSURANCE
ADOI FORM 1115 - January 2020 (ED: 01/20)
INSURER'S (A) RATE REPORTING FORM
In accordance with A.R.S. § 20-382 A(8), on or before January 30, this form is to be completed by the Insurer and filed
with the Department, certifying the Insurer did not have, for the risks written, credible experience to establish a rating
class.
SECTION I (INSURER INFORMATION)
Complete Name Of Insurer:
SECTION II (CERTIFICATION)
I, ______________________________________, in my capacity as _________________________________
(Name of Insurer’s Authorized Representative) (Title of Insurer’s Authorized Representative)
f
or ______________________________________, an insurance company duly authorized under the laws of
(Complete Name of Insurer)
Arizona to transact ________________________________________________________________,
(Enter insurance lines for which insurer has an Arizona certificate of authority)
I do her
eby certify that for the preceding twelve-month period ending December 31, 20___, the aforementioned
insurer applied rates, the insurer developed, individually to the insurance policies of risks located in the State of
Arizona. The rates applied were rates for which no rate service organization has published a rate or loss costs in
Arizona or any other state and for which insufficient similar exposure units and loss experience data exist to
develop statistically credible rates for the risk and no homogeneous rating class exists in which the risk could
reasonably be placed. The aforementioned described rates are for the purposes of this form considered to be
"(A) rates."
____
____________________________________________________________________________________
(SIGNATURE OF INSURER”S AUTHORIZED REPRESENTATIVE)
Insurer is to file the signed and completed form via SERFF under TOI “Company Reports”, Sub-
TOI “A Rate Report”.
Questions regarding these instructions should be referred to the Property and Casualty Section, Arizona
Department of Insurance. propcas@azinsurance.gov
.
