Fillable Financial Affairs Division Arizona Department of Insurance 100 (Arizona)

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Financial Affairs Division Arizona Department of Insurance 100 (Arizona)

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E-MRR.AS (v. 20181105)
Financial Affairs Division
Arizona Department of Insurance
100 North 15
th
Avenue, Suite 102, Phoenix, Arizona 85007-2624
Phone: (602) 364-3999
Web: https://insurance.az.gov
ANNUAL STATEMENT WORKSHEET FOR
DOMESTIC MECHANICAL REIMBURSEMENT REINSURER
ENTER THE CALENDAR YEAR FOR THIS ANNUAL STATEMENT WORKSHEET:
COMPANY:
NAIC#:
DOMICILE:
AZ
THIS WORKSHEET AND THE ANNUAL STATEMENT ARE DUE APRIL 1
Initial at left for each item enclosed with Annual Statement
AGENCY
Use
Only
A. Annual Statement – 8-1/2” X 14” (Proper color jacket, securely bound in two-sided
book form)
MUST INCLUDE THE FOLLOWING TO BE COMPLETE:
1. Jurat Page
a. TWO executive officer original signatures (Names must be on Jurat Page)
b. Notary signature and stamp or seal
2. Actuarial Opinion or Enter N/A in box if your Affidavit of Exemption and a copy
of our letter granting the exemption are enclosed
B. Form E-MRR.05 Annual Report of Policy and Loss Reserves and Application for
Certificate of Authority Renewal
C. Management Discussion & Analysis (due April 1)
D. IF AVAILABLE, Audited Financial Report (due June 1)
MAIL SEPARATELY TO THE FINANCIAL AFFAIRS DIVISION:
Annual Insurance Holding Company System Registration Statement
Form B, C, and F (due March 31)
PREPARED BY:
Name and Title
Phone Number
Email address
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Financial Affairs Division Arizona Department of Insurance 100 (Arizona)

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Completed 12 August 2020

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