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

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Financial Affairs Division Arizona Department of Insurance AUDITED (Arizona)

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E-AFR.GFE (20200220) Page 1 of 2
Financial Affairs Division
Arizona Department of Insurance
Phone: (602) 364-3245
Web: https://insurance.az.gov
AUDITED FINANCIAL REPORT
GUIDELINES FOR EXEMPTIONS
You must file an Audited Financial Report (AFR) with us on or before June 1 as a supplement to your
Annual Statement unless you qualify for an exemption.
Review the following types of exemptions that are available and use only the one exemption provision
that applies to you:
AUTOMATIC EXEMPTION
You qualify for an "automatic" exemption if you have:
a) less than 1,000 policyholders OR certificate holders of direct written policies nationwide
at the end of the calendar year, AND
b) less than $1 million direct ARIZONA premiums written in the calendar year period, AND
c) less than $1 million assumed premiums* pursuant to contracts and/or treaties of
reinsurance.
*If you file the (orange) Health Annual Statement – Use Page 8, Line 12, Column 2.
*If you file the (blue) Life, Accident and Health Annual Statement – Use Schedule T, Line
96, Column 6.
*If you file the (yellow) Property and Casualty Annual Statement - Use the sum of Annual
Statement Page 8, Line 35, Columns 2 and 3.
See Page 2 of this form for the notification to send us. Do not mail the notification with your Annual
Statement.
We may still require you to file an AFR.
STANDARDIZED ORGANIZATIONAL HARDSHIP EXEMPTION
A standardized organizational hardship exemption is available if you are licensed in Arizona only and
meet all of the criteria described in Form E-AFR.OHE.
An affidavit (sample provided in Form E-AFR.OHE) must be filed with a letter requesting this exemption
no later than March 31. Do not mail these items with your Annual Statement. Mail them separately to
the attention of the Financial Affairs Division.
OTHER HARDSHIP EXEMPTION
If you do not qualify for the automatic or standardized organizational hardship exemptions, you may still
apply for an exemption by sending us a letter requesting an organizational or financial hardship
exemption and an affidavit signed by one of your officers avowing to the facts which create the hardship.
We will notify you in writing that your application is granted or denied.
E-AFR.GFE (20200220) Page 2 of 2
AUDITED FINANCIAL REPORT
AUTOMATIC EXEMPTION NOTIFICATION
FOR ARIZONA DOMESTIC COMPANY ONLY
DATE:
COMPANY NAME:
NAIC#:
CALENDAR YEAR:
We are notifying you that we meet the criteria for an automatic exemption from filing an Audited
Financial Report. For the calendar year stated above, we had
1. less than 1,000 policyholders OR certificate holders of directly written policies nationwide at
the end of the calendar year,
Number of policyholders/certificate holders:
AND
2. less than $1 million direct ARIZONA premiums written in the calendar year period, AND
3. less than $1 million assumed premiums pursuant to contracts and/or treaties of reinsurance.
Signature and Title Date
Telephone Number Email Address
Send this notice before March 31
st
to:
Financial Affairs Division
Arizona Department of Insurance
100 North 15th Avenue, Suite 261
Phoenix, AZ 85007-2630
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Financial Affairs Division Arizona Department of Insurance AUDITED (Arizona)

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Completed 12 August 2020

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