Form INS7166 "Audited Financial Statement Exemption Affidavit" - Ohio

Form INS7166 or the "Audited Financial Statement Exemption Affidavit" is a form issued by the Ohio Department of Insurance.

Download a PDF version of the Form INS7166 down below or find it on the Ohio Department of Insurance Forms website.

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Download Form INS7166 "Audited Financial Statement Exemption Affidavit" - Ohio

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Office of Risk Assessment
Ohio Department of Insurance
50 W. Town Street, Ste 300
Mike DeWine – Governor
Columbus, OH 43215
Jillian Froment – Director
(614) 644-2658
Fax (614) 644-3256
Audited Financial Statement Exemption
www.insurance.ohio.gov
Affidavit*
PER NAIC ANNUAL STATEMENT INSTRUCTIONS. FILING DEADLINE IS JUNE 1.
I, THE UNDERSIGNED, HEREBY CERTIFY THAT
(Name of Company)
(Mailing Address)
(City, State, Zip)
(NAIC No.)
(Federal ID No.)
**
AUDITED FINANCIAL STATEMENT AS PERMITTED BY THE CURRENT NAIC
IS EXEMPT FROM FILING A
ANNUAL STATEMENT INSTUCTIONS.
I FURTHER CERTIFY THE AMOUNT OF DIRECT PREMIUMS AND FUND DEPOSITS WRITTEN DURING CALENDAR
YEAR _______ WAS
, THE NUMBER OF POLICYHOLDERS AND INSURANCE CERTIFICATE
HOLDERS AT THE END OF _______ WAS
, AND THE AMOUNT OF ASSUMED PREMIUMS
WRITTEN DURING THE CALENDAR YEAR _______ WAS
.
Signature of Officer
Officer Title
Date
Notary Public
* TO BE FILED IN LIEU OF THE ANNUAL AUDITED FINANCIAL STATEMENT. THIS EXEMPTION APPLIES TO THE
CURRENT FILING PERIOD ONLY.
** YEAR MUST BE ENTERED.
Accredited by the National Association of Insurance Commissioners (NAIC)
INS7166 (Rev. 01/2019)
Page 1 of 1
Office of Risk Assessment
Ohio Department of Insurance
50 W. Town Street, Ste 300
Mike DeWine – Governor
Columbus, OH 43215
Jillian Froment – Director
(614) 644-2658
Fax (614) 644-3256
Audited Financial Statement Exemption
www.insurance.ohio.gov
Affidavit*
PER NAIC ANNUAL STATEMENT INSTRUCTIONS. FILING DEADLINE IS JUNE 1.
I, THE UNDERSIGNED, HEREBY CERTIFY THAT
(Name of Company)
(Mailing Address)
(City, State, Zip)
(NAIC No.)
(Federal ID No.)
**
AUDITED FINANCIAL STATEMENT AS PERMITTED BY THE CURRENT NAIC
IS EXEMPT FROM FILING A
ANNUAL STATEMENT INSTUCTIONS.
I FURTHER CERTIFY THE AMOUNT OF DIRECT PREMIUMS AND FUND DEPOSITS WRITTEN DURING CALENDAR
YEAR _______ WAS
, THE NUMBER OF POLICYHOLDERS AND INSURANCE CERTIFICATE
HOLDERS AT THE END OF _______ WAS
, AND THE AMOUNT OF ASSUMED PREMIUMS
WRITTEN DURING THE CALENDAR YEAR _______ WAS
.
Signature of Officer
Officer Title
Date
Notary Public
* TO BE FILED IN LIEU OF THE ANNUAL AUDITED FINANCIAL STATEMENT. THIS EXEMPTION APPLIES TO THE
CURRENT FILING PERIOD ONLY.
** YEAR MUST BE ENTERED.
Accredited by the National Association of Insurance Commissioners (NAIC)
INS7166 (Rev. 01/2019)
Page 1 of 1
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