Form E-Sl-Final - Arizona Licensed Surplus Lines Broker Final Statement And Premium Tax Report - 2005 Page 2

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ARIZONA LICENSED SURPLUS LINES BROKER FINAL STATEMENT AND PREMIUM TAX REPORT
FOR REPORTING PERIOD OF: _____________________ THROUGH ___________________
DATE OF SURPLUS LINES BROKER LICENSE TERMINATION: ________________________
Arizona Surplus Lines Broker __________________________________________ Arizona License Number
(Type exact name as on license)
PART A - EXHIBIT OF SURPLUS LINES INSURANCE BUSINESS TRANSACTED
Based on Policy Effective Date or Cancellation Effective Date*
Enter "0" or "None" Where Applicable - Do Not File a Blank Statement
(A)
(B)
(C)
(D)
Aggregate Gross
Fire Portion of
Line of Business
Premiums Charged
Return Premiums
Aggregate
Aggregate
Description
Including Fees
Paid to Insureds
Net Premiums
Net Premiums
0.00
Accident & Health
$
(-)$
= $
$
XXXXXXXXXXX
0.00
Automobile Liability
$
(-)$
= $
$
XXXXXXXXXXX
0.00
Automobile Physical Damage
$
(-)$
= $
$
0.00
Aviation Liability
$
(-)$
= $
$
XXXXXXXXXXXX
0.00
Aircraft Physical Damage
$
(-)$
= $
$
0.00
Fire and Allied Lines
$
(-)$
= $
$
0.00
General Liability
$
(-)$
= $
$
XXXXXXXXXXXX
0.00
Inland Marine
$
(-)$
= $
$
0.00
Miscellaneous Special Lines
$
(-)$
= $
$
0.00
Products
$
(-)$
= $
$
Professional Liability and
0.00
Malpractice (Including E & O)
$
(-)$
= $
$
XXXXXXXXXXXX
0.00
0.00
0.00
0.00
1. TOTAL EACH COLUMN
$
(-)$
= $
$
[SL Gross]
[SLF Gross]
2. EXEMPT PREMIUMS – ATTACH LIST IDENTIFYING EACH INSURED, AMOUNTS
AND BASIS OF EXEMPTION
(-)$
(-)$
[SLX ]
3. TOTAL SURPLUS LINES PREMIUMS SUBJECT TO TAX – SUBTRACT LINE 2
0.00
0.00
FROM LINE 1 IN COLUMNS C AND D
= $
= $
[SL Taxable]
[SLF Taxable}
3 %
Surplus Lines Tax Rate
0.00
4. SURPLUS LINES PREMIUM TAX DUE - LINE 3, COLUMN C times 0.03
$
ATTACH THIS PAGE AND ANY SUPPORTING SCHEDULES TO PAGE 1
*The amounts reported above must reflect only those transactions having a policy effective date or a cancellation effective
date within this Semi-Annual Report period. Transactions reported to the Surplus Lines Association of Arizona more than
60 days after the policy effective date or cancellation effective date require an Amended or Supplemental Semi-Annual
Statement Report to be promptly filed with this Department with payment of any additional tax due.
Call (602) 912-8427 for assistance.
E-SL-F
(R
. 06/05)
P
2
2
INAL
EV
AGE
OF

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