2006 Annual Tax And Fees Report Form (Foreign And Alien Fraternal Benefit Society) Page 2
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1
2
3COMPANY NAME
NAIC NO.
2006 RETALIATORY TAXES AND FEES WORKSHEET
In the State of Incorporation Column, enter the amounts that a like Arizona insurer would be required to pay to your state of incorporation, using the Arizona business as the base amount for
fees, assessments and taxes imposed. In the Arizona column, enter only amounts actually paid in 2006.
,
ATTACH TO THIS WORKSHEET PHOTOCOPIES OF PAYMENTS MADE
OR EXPLANATION
. F
AND CALCULATIONS FOR EACH ITEM REPORTED IN THIS WORKSHEET
AILURE TO REPORT AND DOCUMENT RETALIATORY AMOUNTS MAY RESULT IN ASSESSMENTS INCLUDING APPLICABLE PENALTIES
/
AND
OR INTEREST ON A RETALIATORY BASIS
I
! C
MPORTANT
OMPLETE BOTH COLUMNS
State of Incorporation
Arizona
FEES:
(A)
(B)
1.
Certificate of Authority renewal fee paid in 2006
30.00
$
$
2.
Annual Statement filing fee paid in 2006
300.00
$
$
3.
Publication fees paid in 2006
XXXXXXXXXXXXXX
[ A
I
]
TTACH
NVOICE
$
$
4.
Policies, rates and forms filing fees
XXXXXXXXXXXXXX
$
$
Agent fees, IF APPLICABLE. See instructions on Form E-AZ AGENTS and below. Enter TOTALS from
0.00
5.
$
$
below
6.
Other fees (filing articles, bylaws, amendments)
$
$
0.00
330.00
SUBTOTAL #1 ( Add lines 1 through 6)
$
$
ASSESSMENTS:
7.
Fraud Fund Assessment
[ Attach Documentation ]
$
$
8.
Fraudulent Claims Assessment
XXXXXXXXXXXXXX
$
$
9.
XXXXXXXXXXXXXX
Health Care Appeals Fund Assessment
$
$
10.
Other State of Incorporation Special Assessments
XXXXXXXXXXXXXX
[ Attach Documentation ]
$
$
11.
Other State of Incorporation Assessments
XXXXXXXXXXXXXX
[ Attach Documentation ]
$
$
0.00
0.00
SUBTOTAL #2 ( Add lines 7 through 11 )
$
$
TAXES:
12.
State income tax paid/payable for 2006
XXXXXXXXXXXXXX
[ Attach Pro Forma Return ]
$
$
13.
State income tax credit against premium tax for 2006
XXXXXXXXXXXXXX
(-)
$
14.
State franchise tax paid/payable for 2006
XXXXXXXXXXXXXX
[ Attach Pro Forma Return ]
$
$
15.
State franchise tax credit against premium tax for 2006
XXXXXXXXXXXXXX
(-)
$
16.
Other State of Incorporation Taxes
XXXXXXXXXXXXXX
[ Attach Documentation ]
$
$
0.00
0.00
SUBTOTAL #3 ( Add lines 12 through 16 )
$
$
330.00
17.
0.00
RETALIATORY WORKSHEET TOTALS (Add Subtotals 1, 2 and 3)
$
$
Enter line 17 amounts on Page 3, line 13
COMPANY AGENT FEES Line 5
ONLY INSURERS whose domiciliary state requires ARIZONA INSURERS to pay fees for the license, OR appointment OR
termination of their agents in that state SHALL complete Form E-AZ AGENTS and attach it to this schedule. Complete only the columns that are applicable. For example, if your state
requires insurers to only pay appointment fees, then complete only that column. After completing Form E-AZ-AGENTS, carry totals forward to applicable sections A and/or B and/or C
below.
P
’
I
D
’
A
Department.
LEASE VERIFY YOUR STATE
S REQUIREMENTS WITH THEIR
NSURANCE
EPARTMENT AND YOUR COMPANY
S
CCOUNTING
COMPLETE PART A BELOW ONLY IF YOUR STATE OF INCORPORATION REQUIRES ARIZONA INSURERS TO PAY AGENT LICENSE FEES.
COMPLETE PART B BELOW ONLY IF YOUR STATE OF INCORPORATION REQUIRES ARIZONA INSURERS TO PAY AGENT APPOINTMENT FEES.
COMPLETE PART C BELOW ONLY IF YOUR STATE OF INCORPORATION REQUIRES ARIZONA INSURERS TO PAY AGENT TERMINATION FEES.
STATE OF INCORPORATION
ARIZONA
Enter the figure from line 1 of Part D on Page 2 of FORM E-AZ AGENTS in BOTH Columns ⇒⇒⇒⇒⇒⇒⇒⇒⇒⇒
#
#
A.
Enter $ amount from line 2,
Enter the AGENT LICENSE FEE amount that was in effect in the State of Incorporation during 2006. (Do not include
Part D, on Page 2 of Form E-
any late fees)
X $
AZ AGENTS below
Total 2006 agent license fees. Multiply the 2 lines above for the State of Incorporation column and enter the result.
$
$
0.00
⇓
Enter TOTAL from COLUMN 3 on Page 1 of FORM E-AZ AGENTS in STATE OF INCORPORATION Column ⇒⇒⇒
#
B.
Enter the AGENT APPOINTMENT FEE amount that was in effect in the State of Incorporation during 2006 (Do not
⇓
X $
include any late fees)
Total 2006 agent appointment fees. Multiply the 2 lines above and enter the result. ⇒⇒⇒⇒⇒⇒⇒⇒⇒⇒⇒⇒⇒⇒
$
0.00
⇓
C. Enter TOTAL from COLUMN 4 on Page 1 of FORM E-AZ AGENTS in STATE OF INCORPORATION Column
#
⇒⇒⇒
⇓
Enter the AGENT TERMINATION FEE amount that was in effect in the State of Incorporation during 2006. (Do not
include any late fees)
X $
⇓
Total 2006 agent termination fees. Multiply the 2 lines above and enter the result. ⇒⇒⇒⇒⇒⇒⇒⇒⇒⇒⇒⇒⇒⇒⇒
$
0.00
$
$
TOTALS - ENTER SUM OF SECTION A, B AND C TOTALS IN SHADED BOXES. CARRY THESE TOTALS TO LINE 5 ⇒⇒⇒
0.00
E-FRATERNAL (R
. 12/06)
STATE OF ARIZONA
P
2
3
EV
AGE
OF
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