Fillable CAPTIVE INSURER ANNUAL REPORT AND RENEWAL FEE TRANSMITTAL (Arizona)

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CAPTIVE INSURER ANNUAL REPORT AND RENEWAL FEE TRANSMITTAL (Arizona)

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Captive Insurance Division
Arizona Department of Insurance
100 North 15
th
Avenue, Suite 102, Phoenix, Arizona 85007-2624
Phone: (602) 364-4490 | Web: https://insurance.az.gov
CAPTIVE INSURER ANNUAL REPORT AND RENEWAL FEE TRANSMITTAL
File your annual report using the Captive Insurer Annual Report web portal, accessible from
https://insurance.az.gov/insurers/financial-reporting-domestic-entities/captive-insurer
CID-AR-Transmittal (10/2018)
INFORMATION ABOUT THE CAPTIVE INSURER
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 required reporting documents through the portal no later than the applicable due date)
☐ $5,500.00 (Pay Code 87) Certificate of Authority Renewal Fee
●Make payable to Arizona Department of Insurance. ●Write the license/NAIC number in the memo section of
the payment or on 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.
☐ Captive Insurer Annual Report Jurat Page signed by two officers of the captive insurer
and the captive manager and submitted as an Adobe Acrobat PDF file.
☐ Captive Insurer Annual Report, submitted as a Microsoft Excel workbook
Actuarial Opinion: Adobe Acrobat PDF file of one of the following:
☐ Actuarial opinion (including Exhibits A and B) OR
☐ exemption reason OR
☐ requirement waiver reason
☐ Actuarial Opinion Summary (if not exempt or waived): Adobe Acrobat PDF file
☐ Management Discussion and Analysis – original plus one printed copy
☐ Form E-178: Certificate of Disclosure
☐ Annual audited financial report, unless exempt or waived ☐
☐ Most recent financial statements of the captive’s parent
IMPORTANT: Any captive insurer 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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CAPTIVE INSURER ANNUAL REPORT AND RENEWAL FEE TRANSMITTAL (Arizona)

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Completed 12 August 2020

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