E-ACTOP (v. 20181218)
Financial Affairs Division
Arizona Department of Insurance
100 North 15
th
Avenue, Suite 261, Phoenix, Arizona 85007-2630
Phone: (602) 364-3245
Web: https://insurance.az.gov
ARIZONA DOMESTIC INSURERS
(NOT APPLICABLE TO LIFE INSURERS)
ACTUARIAL OPINION “FINANCIAL HARDSHIP” EXEMPTION APPLICATION
Applications must be in Affidavit form signed by one of your executive officers.
The Affidavit form must indicate the basis for the financial hardship, and must include the
following information:
a. Projected reasonable cost of obtaining an actuarial opinion,
Must attach: A written estimate from a qualified actuary in sufficient detail to present
the “projected reasonable cost” of the actuary’s services.
b. One percent of capital and surplus as of your latest quarterly statement for the
calendar year for which the exemption is sought equals $ ,
or
If you did not file quarterly financial statements during the subject calendar year, one
percent of capital and surplus as of December 31 of the calendar year prior to the
year for which the actuarial opinion exemption is being requested equals
$ .
c. Three percent of your net direct plus assumed premiums written during the calendar
year for which the exemption is sought as projected from your latest quarterly
statement filed with us equals $ , or
If you did not file quarterly financial statements during the subject calendar year,
three percent of your net direct plus assumed premiums written during the calendar
year for which the actuarial opinion exemption is being requested is estimated to be
$ .
Any additional information that is directly relevant to the application may be provided in sufficient
detail to permit us to make an informed decision with respect to the requested exemption. If you
assume business only, explain why an Actuarial Opinion is not available from your ceding
insurer(s).
The application (affidavit and attachment) must include a letter of intent and must be filed
no later than December 1 of the calendar year for which the exemption is to be claimed.
We may deny the exemption prior to December 31 of the same year if we deem the exemption
inappropriate.
A copy of the approved exemption must be filed with the annual statement in all jurisdictions in
which you are authorized.
