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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  • 8 check-boxes
  • 20 other fields

Country of origin: US
File type: PDF

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100 North 15
th
Avenue, Suite 261
Phoenix, Arizona 85007-2630
Phone: (602) 364-4490
Web: https://difi.az.gov/
CAPTIVE INSURER ANNUAL REPORT AND RENEWAL FEE TRANSMITTAL
File your annual report using the Captive Insurer Annual Report web portal.
CID-AnnRepTrans (01 2021)
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 check payable to Arizona Department of Insurance and Financial Institutions.
●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: Adobe Acrobat PDF file
☐ Form E-178: Certificate of Disclosure: Adobe Acrobat PDF file
☐ Annual audited financial report, if not exempted or waived: Adobe Acrobat PDF file
☐ Most recent financial statements of the captive’s parent: Adobe Acrobat PDF file
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 1 July 2022

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