Premium Receipts Tax Return Of Industrial Insured Form - Department Of Insurance State Of Arizona

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DEPARTMENT OF INSURANCE
Reset
STATE OF ARIZONA
Financial Affairs Division- Tax Unit
PREMIUM RECEIPTS TAX RETURN OF INDUSTRIAL INSURED
th
2910 North 44
Street, Suite 210
Phoenix, Arizona 85018-7269
Phone: (602) 364-3246
Fax: (602) 364-3989
CALENDAR YEAR _______
NAME OF INDUSTRIAL INSURED Filing Return (See Form E-INDINS.I
)
NSTRUCTION
INSURED’S COMPLETE BUSINESS ADDRESS
PHONE NUMBER (See Instruction 4)
Column A
Column B
Column C
Column D
Column E
Column F
Column G
Column H
Premium Allocated to Arizona
Policy
Name & Business
Type of Insurance and
Effective
Expiration
Date Premium
Gross Premium
Risks or Exposures
Number
Address
Description of
Date
Date
Charged
Charged
(See Instruction 8)
(See Instruction
(See Instruction 7)
of Unauthorized Insurer
Coverage
6)
(See Instruction 5)
Code #
%
Amount
*
0.00
0.00
0.00
0.00
0.00
0.00
Column G Total: $
Column H Total: $
Code # Column - Apportionment Standards and Code Letters
(See Instruction 8 and Form E-INDINS.A
)
LLOCATION
0.00
Line 1: Taxable Arizona Premiums = Column H Total:
$
EP =
% of Employee Payroll in Arizona
[II Gross / Tax]
PA =
% of Physical Assets in Arizona
Line 2: Tax Due = 3% (0.03) of amount entered on line
0.00
1 above:
S =
$
% of Sales in Arizona
Pay Code 08]
TI =
[
% of Taxable Income in Arizona for State Income Tax Purposes
MAIL ALL FORMS WITH CHECK (Payable to ARIZONA DEPARTMENT OF INSURANCE) TO ADDRESS SHOWN ABOVE
I, the undersigned, am an officer of, or am authorized to act for, the Insured and do hereby certify that the above is a true, correct and complete
return by the named Insured of all insurance procured or renewed with an unauthorized or non-admitted insurer during the calendar year stated
above, that includes coverage for risks or exposures wholly or partially located in Arizona and that I have endeavored to equitably allocate the
portion of premiums applicable to the State of Arizona as presented in Form E-INDINS.A
, which, if applicable, is attached to this return.
LLOCATION
By:
Name of Organization or Entity
Signature
Date of Signing ( See Instruction 10)
Type or Print Name and Title (See Instruction 10)
THIS RETURN AND TAX PAYMENT ARE DUE BY MARCH 1 FOLLOWING THE TRANSACTION CALENDAR YEAR END
ATTACH COMPLETED, SIGNED AND NOTARIZED FORMS E-INDINS.ALLOCATION AND E-INDINS.CERTIFICATION TO THIS RETURN
E-INDINS.T
(R
. 12/09)
P
1
1
AX
EV
AGE
OF

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