Form E-Ucldr - Annual Fees Report Domestic Unaffiliated Credit Life And Disability Reinsurer 2002

ADVERTISEMENT

ARIZONA DEPARTMENT OF INSURANCE
2002 ANNUAL FEES REPORT
DOMESTIC UNAFFILIATED CREDIT LIFE AND DISABILITY REINSURER
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
Arizona Company 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 August 1, 2003 if the Reinsurer's fiscal year end is December 31st
or November 1, 2003 if the Reinsurer's fiscal year ends on a date other than December 31st.
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:
$
4,800.00
A
R
I
Z
O
N
A
D
E
P
A
R
T
M
E
N
T
O
F
I
N
S
U
R
A
N
C
E
M
A
R
I
Z
O
N
A
D
E
P
A
R
T
M
E
N
T
O
F
I
N
S
U
R
A
N
C
E
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 Unaffiliated Credit Life & Disability Reinsurer named above did not write direct premiums in the state of Arizona during
2002 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
I certify that I have examined this report. It is true, complete and correct to the
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 the due date is subject to a late penalty fee not to exceed $25 per day for each
day of delinquency.
E-UCLDR (R
. 12/02)
P
1
1
EV
AGE
OF

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go