E-MAA (v. 20181218)
Financial Affairs Division
Arizona Department of Insurance
100 North 15
th
Avenue, Suite 102, Phoenix, Arizona 85007-2624
Phone: (602) 364-3986
Web: https://insurance.az.gov
MUTUAL AID ASSOCIATION FILING REQUIREMENTS
ARS § 20-893
On or before June 1 of each year, each association and order should:
1. Complete and file this form.
2. File a true and complete statement of its statutory financial condition, transactions and affairs for the preceding
calendar year, audited by an independent certified public accountant.
3. File an actuarial memorandum issued by a qualified actuary pursuant to ARS § 20-696.04.
4. Remit a $300.00 check made payable to the Arizona Department of Insurance.
SEND DOCUMENTS TO:
Financial Affairs Division
Arizona Department of Insurance
100 North 15
th
Avenue, Suite 102
Phoenix, AZ 85007-2624
If the due date falls on a Saturday or Sunday, the deadline will be extended to the following Monday for that year
only. Please note our “postmark policy” as it is enforced by this Department: to be considered a timely filing, the
package containing the filing must display validation by the United States Postal Service* as proof of the date of
filing. Courier deliveries must include an invoice bearing the date of courier pick-up. If your package does not
provide evidence of a timely mailing it will be considered filed when received and statutory penalties, where
applicable, will be assessed. *Postage meter stamps do not qualify.
Name of Entity AZ#
Premiums written in Arizona $
Contact Name Telephone Number Email Address
All policies and/or contracts issued pursuant to the exemption prescribed in Arizona Revised Statutes § 20-
893(A)(3) must contain a conspicuously stamped or written notice in bold type that states:
This policy is issued by an association or order that does not possess a Certificate of Authority from the Director
of the Arizona Department of Insurance. If the association or order that issued this policy becomes insolvent,
members or claimants will not be eligible for insurance guaranty fund protection pursuant to Title 20, Arizona
Revised Statutes.
