Form E-Lr - Annual Fees Report Domestic Life & Disability Reinsurer - 2001
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1ARIZONA DEPARTMENT OF INSURANCE
2001 ANNUAL FEES REPORT
DUE DATE: MARCH 31, 2002
DOMESTIC LIFE & DISABILITY REINSURER
PREMIUM TAX UNIT
(602) 912-8429
FAX (602) 912-8421
For Office Use Only
For Audit Use Only
Complete Company Name and Home Office Address
State of Incorporation
X
X
ARIZONA
X
NAIC Number
X
NAIC Group Number
X
Federal I. D. Number
X
Preparer’s Name and Title:
E-Mail Address:
Toll Free or Collect Phone: (
)
FAX: (
)
Complete Mail Address:
Summary of Annual Fees Due March 31, 2002
1)
Certificate of Authority Renewal Fee
$
4,500.00
(Pay Code 57)
2)
Annual Statement Filing Fee
$
300.00
(Pay Code 28)
3)
TOTAL DUE MARCH 31, 2002
$
4,800.00
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AKE CHECK PAYABLE TO AND
Attention: TAX UNIT
M
:
2910 North 44
Street, Second Floor
AIL CHECK WITH REPORT TO
th
Phoenix, Arizona 85018-7256
It is hereby certified that the Domestic Life & Disability Reinsurer named above did not write direct premiums in the state of Arizona during Calendar Year
2000 and does not owe premium taxes prescribed by A.R.S. § 20-224.
PREPARER CERTIFICATION
COMPANY OFFICER CERTIFICATION
I certify that I have prepared this report. It is true, complete and correct to the
I certify that I have examined this report. It is true, complete and correct to the
best of my knowledge.
best of my knowledge.
SIGNATURE OF PREPARER
DATE
SIGNATURE OF OFFICER
DATE
NAME AND TITLE TYPED OR PRINTED
NAME AND TITLE TYPED OR PRINTED
FAILURE TO FILE AN ANNUAL STATEMENT OR PAY FEES:
Any insurer failing to file an annual statement or to pay its fees on or before March 31 is subject to a late penalty fee not to exceed $25 per day for
each day of delinquency.
E-LR (R
. 12/01)
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