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Credit Property Form
CPFORM (v 20201031)
CREDIT PROPERTY EXPERIENCE REPORT, ANNUAL STATEMENT SUPPLEMENT – Due April 1
st
Complete this form in compliance with A.R.S. §20-1621.06 and A.A.C. R20-6-604.07
CO. NAME:
NAIC CO. CODE:
Calendar Year: Number of policies/certificates:
Check box if NO written premium/policies issued and go to Contact area and Filing
Instructions.
PART 1. Class of Business
CREDITOR OR FORCED PLACEMENT
Is the business creditor-placed and/or under force placed? If the answer is yes to either of these, then please
skip to Part 2
Yes
No
Is the Property insured real property? If so, check “Real Property” in the first column below, and proceed to
Part 2
SECURITIAZTION: (Check one)
Auto
Not Secured
Real Property
Home Equity
Personal Property
Personal Property
Other (Describe)
Other (Describe)
CLASSES OF BUSINESS: (Check one)
a. Credit Unions
b. Bank, Savings and Loan Institutions, Mortgage Companies
c. Finance Companies, Small Loan Companies and ARS 6-601(5) Consumer Lenders
d. Dealers including auto, truck or boat, retail stores or other individuals selling financed goods
e. All other persons selling Credit Insurance not specifically listed above
MODE OF PREMIUMS PAYMENT: (Check one)
COVERAGES PROVIDED: (Check all that
apply)
Single Premium
Fire and Extended Coverage
Monthly Outstanding Balance (MOB)
Theft
Other (Describe)
Other (Describe)
TYPE OF INTEREST: (Check one)
TYPE OF LOAN: (Check all that apply)
Dual Interest
Closed End Plan of Indebtedness
Single Interest
Open Ended plan of Indebtedness
Other (Describe)
Other (Describe)
Reset
CPFORM (v 20201031)
Part 2. Arizona Premiums and Losses
1. ARIZONA – EARNED PREMIUMS:
1a
Gross Written Premiums
1b
Refunds on terminations
1c
Net written premiums (lines 1a – 1b)
1d
Premium reserves, start of period
1e
Premium reserves, end of period
1f
Actual earned premiums (lines 1c + 1d - 1e)
1g
Earned premiums at prima facie rates
2. ARIZONA – INCURRED CLAIMS:
2a
Claims paid
2b
All claim reserves, start of period
2c
All claim reserves, end of period
2d
Incurred claims (lines 2a – 2b + 2c)
2e
Paid claim count
3. ARIZONA – PRODUCT SPECIFIC EXPENSES:
3a
Commissions and Service Fees incurred
3b
Other incurred compensation
3c
Defense and cost containment expenses incurred (ref. 5.1)
3d
Adjusting and other expense incurred (ref. 5.2)
3e
Premium Taxes incurred
4. ARIZONA – POLICY DATA:
4a
Rate in effect on the later of 1/1/03 or product inception
4b
Rate change dates and new rates
4c
Policies in force at the beginning of the year — Policy Count
4d
Policies in force at the end of the year
Part 3 – Countrywide Premiums and Losses
5. COUNTRYWIDE – EARNED PREIMIUMS:
5a
Gross Written Premiums
5b
Refunds on termination
5c
Net written premiums (lines 5a – 5b)
5d
Premium reserves, start of period
5e
Premium reserves, end of period
5f
Actual earned premiums (lines 5c + 5d – 5e)
5g
Earned premiums at prima facie rates
6. COUNTRYWIDE – INCURRED CLAIMS:
6a
Claims paid
6b
All claim reserves, start of period
6c
All claim reserves, end of period
6d
Incurred claims (lines 6a – 6b + 6c)
6e
Paid claim count
0
0
0
0
0
0
CPFORM (v 20201031)
7. COUNTRYWIDE – PRODUCT SPECIFIC EXPENSES:
7a
Commissions and service Fees incurred
7b
Other incurred compensation
7c
Defense and cost containment expense incurred (ref. 5.1)
7d
Adjusting and other expense incurred (ref. 5.2)
7e
Premium Taxes incurred
8. COUNTRYWIDE – POLICY DATA:
8a
Rate in effect on the later of 1/1/03 or product inception
8b
Rate change dates and new rates
8c
Policies in force at the beginning of the year – Policy Count
8d
Policies in force at the end of the year
CONTACT:
Preparer’s Name
Title
Email Address
Phone Number
Signature
Date
FILING INSTRUCTIONS:
Name the document using this format: CP-[YEAR]-[NAIC#]-[InsurerName] (e.g. CP-2019-12345-
InsurerName)
E-mail completed Form to the propcas@difi.az.gov Put “CP Experience Report” and Name of Insurer in
subject line.
DO NOT MAIL ORIGINAL/HARDCOPY DOCUMENT
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Completed 1 July 2022

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