E-PC.350 (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/
PRODUCER CONTROLLED PROPERTY AND CASUALTY INSURANCE REPORT
DUE APRIL 1
Required to be completed and filed by Arizona Domestic property and/or casualty insurer
ENTER THE CALENDAR YEAR FOR WHICH THIS REPORT IS BEING FILED:
Instructions: Each domestic insurer licensed to transact property or casualty insurance is required to
complete Section I of this form for each producer who "controls" such insurer OR Section II of this form indicating
that the requirements of Arizona Revised Statutes § 20-487 et seq. have been reviewed and that there is no
controlling producer information to be reported.
SECTION I - To be completed by a producer controlled property and/or casualty insurer
Name of Controlling Producer:
Controlling Producer Arizona License Number:
1. Amount of commission paid to Controlling Producer:
2. Percentage such amount represents of net premium written:
3. Comparable amounts and percentages paid to non-controlling producers for placement of the same kinds
of insurance:
Attach a list if more space needed.
4. As required by ARS § 20-487.02(C), attach the opinion of an independent casualty actuary or other independent
loss reserve specialist who is acceptable to the Director, that reports loss ratios for each line of business written
and attests to the adequacy of loss reserves established for losses incurred and outstanding, including incurred
but not reported, as of the year end on business placed by the producer.
PREPARED BY:
Preparer’s Name and Title
SECTION II - To be completed by a property and/or casualty insurer that is NOT producer controlled
It is hereby certified that the Reporting Insurer named above is not issuing any property or casualty insurance
coverage that are, or may be, reportable under ARS § 20-487 et seq.
Authorized Signature for Certification
Authorized Signer’s Name and Title
