Fillable Form 1: Web: https://insurance.az.gov CREDIT LIFE, DISABILITY AND (Arizona)

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Form 1: Web: https://insurance.az.gov CREDIT LIFE, DISABILITY AND (Arizona)

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Arizona Department of Insurance
Phone: (602) 364-2393
Web: https://insurance.az.gov
Propcas@azinsurance.gov
Credit Life/Disability/Unemployment Form
CLDUFORM (Revised 03/21/2019)
CREDIT LIFE, DISABILITY AND UNEMPLOYMENT EXPERIENCE REPORT – Due April
1
st
Complete this form in compliance with A.A.C. R20-6-604.07
CO. NAME:
NAIC CO. CODE:
Calendar Year:
Check box if NO written premium/policies issued and go to Contact area and Filing Instructions.
Part 1. Class of Business
CLASSES OF BUSINESS: (Check one)
a.
Credit Unions
b.
Bank, Savings and Loan Institutions, Mortgage Companies
c.
Finance Companies, Small Loan Companies and ARS 6-601(5) Consumer Lenders
d.
Dealers including auto, truck or boat, retail stores or other individuals selling financed goods
e.
All other persons selling Credit Insurance not specifically listed above
MODE OF PREMIUM PAYMENT: (Check one)
Single Premium
Monthly Outstanding Balance (MOB)
(MOB) Revolving Account
P
LAN OF BENEFITS: (Check all that apply)
CREDIT LIFE
Decreasing
Gross
Level
Net
CREDIT DISABILITY
14 Day
Single Life
Retro
30 Day
Joint Life
Non Retro
Other (Describe)
CREDIT UNEMPLOYMENT
30 Day
Single Life
Retro
Joint Life
Non Retro
Other (Describe)
PART 2. Arizona Premiums and Losses
1. EARNED PREMIUMS:
1a
Gross Written Premiums
1b
Refunds on terminations
1c
Net written premiums (lines 1a – 1b)
1d
Premiums reserves, start of period
1e
Premium reserves, end of period
1f
Actual earned premiums (lines 1c + 1d – 1e)
1g
Earned premiums at prima facie rates
Reset Form
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CLDUFORM (Revised 03/21/2019)
2. INCURRED CLAIMS:
2a
Claims paid
2b
Unreported claim reserves, start of period
2c
Unreported claim reserves, end of period
2d
Claim reserves, start of period
2e
Claim reserves, end of period
2f
Incurred claims (lines 2a – 2b + 2c – 2d + 2e)
3. INCURRED COMPENSATION:
3a
Commissions and Service fees incurred
3b
Other incurred compensation
3c
Total incurred compensation (lines 3a + 3b)
3d
Commissions / Service fee percentage (lines 3a ÷ 1c)
3e
Other incurred compensation percentage (lines 3b ÷ 1f)
4. LOSS PERCENTAGE
4a
Actual loss percentage (lines 2f ÷ 1f)
4b
Loss percentage at prima facie rates (lines 2f ÷ 1g)
5. MEAN INSURANCE IN FORCE (MIF) (For Credit Life Only)
6. LOSSES PER $1,000 MIF: (1,000 x line 2f ÷ Item 5)
CONTACT:
Preparer’s Name
Title
Email Address
Phone Number
Signature
Date
FILING INSTRUCTIONS:
Name the document using this format: CLDU-[YEAR]-[NAIC#]-[InsurerName] (e.g. CLDU-2019-12345-
InsurerName)
E-mail completed Form to the propcas@azinsurance.gov
Put “CLDU Experience Report” and Name of Insurer in
subject line.
DO NOT MAIL ORIGINAL/HARDCOPY DOCUMENT
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Form 1: Web: https:insurance.az.gov CREDIT LIFE, DISABILITY AND (Arizona)

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Completed 12 August 2020

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