Fillable CERTIFICATION OF DOMESTIC UNAFFILIATED CREDIT LIFE AND DISABILITY (Arizona)

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CERTIFICATION OF DOMESTIC UNAFFILIATED CREDIT LIFE AND DISABILITY (Arizona)

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E-UCLDRCERT (v 20201031) Page 1 of 2
CERTIFICATION OF DOMESTIC UNAFFILIATED CREDIT LIFE AND DISABILITY REINSURER
ARS § 20-1082(2)
To be filed with initial application and each Annual Statement
Full and Exact Corporate Name
NAIC Number
Federal ID Number
December 31
Check one:
Initial Application
Annual Certification
The undersigned hereby certify that we comply in all respects with the requirements of
Arizona Revised Statutes applicable to Unaffiliated Credit Life and Disability Reinsurers
including without limitation, the following:
1. Our insurance operations consist solely of reinsurance of credit life or credit disability insurance that is
issued according to Arizona Revised Statutes Title 20, Chapter 6, Article 10, or that is issued according
to substantially similar laws of another state by an insurer that is authorized in Arizona.
2. We are not “affiliated,” as defined in ARS § 20-481, with any other insurer as defined in ARS § 20-104.
3. We possess and will maintain unimpaired capital stock of not less than seventy-five thousand dollars
($75,000) as ARS § 20-1085(B) requires, and;
Check one only:
Our unimpaired capital is not represented by a letter of credit.
Our unimpaired capital is represented by a clean, irrevocable and unconditional letter of credit
issued by a Qualified Financial Institution, as defined in ARS § 20-261.03 and as approved by you,
that is payable to the Director of Insurance and Financial Institutions and contains a qualifying
“Evergreen Clause” that it is automatically renewable and the issuing financial institution will provide
you not less than 60 days advance written notice of non-renewal. The letter of credit is (check box
that applies)
enclosed, or
on deposit with the State Treasurer’s Office
4. We are and will remain in compliance with ARS § 20-1094 regarding the filing and approval of
reinsurance agreements, and with ARS § 20-260 regarding the limitation of risk (retention on any one
risk shall not exceed 10% of our capital and surplus). Attached to this certification is:
a) A list of all of our reinsurance agreements that includes for each:
i) Name of ceding insurer
ii) Effective date of agreement and of any amendments
iii) Method of security (i.e., funds withheld, trust account, or letter of credit)
iv) Date approved by you or if approval is pending, state “pending”
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CERTIFICATION OF DOMESTIC UNAFFILIATED CREDIT LIFE AND DISABILITY REINSURER
ARS § 20-1082(2)
E-UCLDRCERT (v 20201031) Page 2 of 2
b) For initial applications only – Check each statement below that applies:
i) For each approved agreement, a copy of the cover page bearing your “Approved”
stamp.
ii) For each agreement enclosed, two (2) copies of the agreement and any related trust
agreements.
iii) For each trust agreement, a completed Form E1603, Trust Agreement Checklist.
5. Liabilities that are assumed under reinsurance agreements are secured with (check one that applies)
funds withheld by the ceding insurer, or
funds maintained in a trust account that complies with AAC R20-6-1603 or with a substantially similar
rule of the ceding insurer’s state of domicile, in an amount that is not less than one hundred ten
percent of the amount of the liabilities assumed, or
clean, irrevocable and unconditional Letter(s) of Credit that comply with AAC R20-6-1604 and ARS
§ 20-1094.01.
AFFIDAVIT OF VERIFICATION
State of
)
) ss
County of
)
, President and,
Secretary of
, being duly sworn, each
for him(her)/self deposes and says that they have reviewed the above statements and have performed
any steps to obtain reasonable assurance of their truthfulness, and that the above statements are full and
true according to the best of their information, knowledge and belief, respectively.
President
Secretary
Subscribed and sworn to before me this
day of
,
Notary Public
Commission Expires:
A certified Corporate Resolution of Authorization is attached for signers other than our
President and Secretary.
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CERTIFICATION OF DOMESTIC UNAFFILIATED CREDIT LIFE AND DISABILITY (Arizona)

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Completed 1 July 2022

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