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THIS WORKSHEET AND THE ANNUAL STATEMENT ARE DUE (Arizona)

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E-LR.AS (v. 20200220)
Financial Affairs Division
Arizona Department of Insurance
100 North 15
th
Avenue, Suite 261, Phoenix, Arizona 85007-2630
Phone: (602) 364-3999
Web: https://insurance.az.gov
ANNUAL STATEMENT WORKSHEET FOR
DOMESTIC LIFE AND DISABILITY REINSURER
ENTER THE CALENDAR YEAR FOR THIS ANNUAL STATEMENT WORKSHEET:
COMPANY:
NAIC#:
DOMICILE:
AZ
THIS WORKSHEET AND THE ANNUAL STATEMENT ARE DUE MARCH 31
Initial
if
Enclosed
Initial at left of each item enclosed with Annual Statement
AGENCY
Use
Only
A. Annual Statement – 8-1/2” X 14” (Proper color jacket, securely bound in two-sided
book form)
MUST INCLUDE THE FOLLOWING TO BE COMPLETE:
1. Jurat Page
a. TWO executive officer original signatures (Names must be listed on Jurat
Page)
b. Notary signature and stamp or seal
2. Actuarial Opinion (Enter N/A in box if premiums and reserves = Zero
3. Life Risk Based Capital Report (Hard copy only)
B. Form E-178 Certificate of Disclosure
MUST BE FILED ELECTRONICALLY and INCLUDE THE FOLLOWING TO BE
COMPLETE:
1. Part A must be answered yes or no (If yes, must have attachment)
2. Part B must be answered yes or no (If yes, must have attachment)
3. TWO executive officer electronic signatures (Names must be on Jurat Page)
C. Management Discussion & Analysis (due April 1)
D. IF AVAILABLE, Audited Financial Report
PREPARED BY:
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Phone Number
Email address
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THIS WORKSHEET AND THE ANNUAL STATEMENT ARE DUE (Arizona)

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Completed 12 August 2020

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