E-MRR.05 (v. 20181116)
Financial Affairs Division
Arizona Department of Insurance
Web: https://insurance.az.gov
ANNUAL REPORT OF POLICY AND LOSS RESERVES AND
APPLICATION FOR CERTIFICATE OF AUTHORITY RENEWAL FOR
DOMESTIC MECHANICAL REIMBURSEMENT REINSURER
ARS § 20-1096.05 - DUE APRIL 1
CALENDAR YEAR FOR WHICH POLICY AND LOSS RESERVES ARE BEING REPORTED:
1. A) Amount of policy reserves (unearned premiums) as of December 31 of the year entered above
B) State in detail the method used to determine policy reserves in the calendar year entered above.
2. A) Amount of loss reserves as of December 31 of the year entered above.
B) State in detail the method used to determine loss reserves in the calendar year entered above.
We certify that this policy and loss reserves report is true, complete and correct to the best of our
knowledge and belief.
We hereby apply for renewal of the Company’s Certificate of Authority authorizing it to transact the
business of mechanical reimbursement reinsurance in the State of Arizona under Arizona Revised
Statutes (ARS) Title 20, Chapter 4, Article 12. We affirm that the Company: is a corporation
incorporated under the laws of the State of Arizona; has directors and management that are competent
and trustworthy and are capable of successfully managing its affairs in compliance with law; has made
the deposit required by ARS § 20-1096.06, and it continues to be in compliance with all applicable laws.
