Fillable DO NOT FILE THIS REPORT IF THE INSURER (Arizona)

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DO NOT FILE THIS REPORT IF THE INSURER (Arizona)

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E-PC.INDINS (v 20201031)
REPORT OF POLICIES ISSUED TO INDUSTRIAL INSURED- ARS § 20-400.10(F)
DO NOT FILE THIS REPORT IF THE INSURER DID NOT ISSUE A POLICY TO AN INDUSTRIAL INSURED
Insurer Name – provide exact name
Calendar or Fiscal Year End Date
NAIC Number
Domiciliary State
Contact Name
Each insurer that issues a policy to an Industrial Insured, as defined in ARS § 20-401.07, SHALL report the
information below for all policies issued by the insurer named above to Industrial Insureds for the calendar year
period.
1. Total number of policies written
#
2. Total premiums written
$
3. Total premiums earned
$
4. Total losses paid
$
5. Total losses incurred
$
6. Total number of claims incurred
#
DUE DATES:
Foreign and Alien domiciled insurers – On or before March 1 of each year.
Arizona domiciled insurers – On or before March 31 of each year.
FILING INSTRUCTIONS:
Name the document using this format “INDINS-NAIC Number-Insurer Name” (e.g. INDINS-55555-INSURERNAME).
Send completed form to financialfilings@difi.az.gov
.
DO NOT MAIL ORIGINAL / HARDCOPY DOCUMENT
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DO NOT FILE THIS REPORT IF THE INSURER (Arizona)

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Completed 1 July 2022

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