Form E-Ppd - Annual Net Charges Tax And Fees Report - 2000 Page 2
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1
2
3COMPANY NAME
NAIC NO.
PART A – RECONCILIATION OF ARIZONA TAXABLE NET PREPAID
CHARGES AND COMPUTATION OF TAX DUE
Attach copies of Pages 2, 3, and 4 and Schedules F and T of your 2000 Annual Statement to complete this report.
1.
Gross Arizona Net charges Earned
(Annual Statement, Schedule T [Page 56], column 4, line 3)
$
2.
Plus: Arizona Premiums Receivable at 12/31/99
$
3.
Minus: Arizona Premiums Receivable at 12/31/00
(-)$
4.
Plus: Unearned Arizona Premiums at 12/31/00
$
5.
Minus: Unearned Arizona Premiums at 12/31/99
(-)$
6.
Total Arizona Collected Premiums
$
line 1+ 2 -3 +4 -5)
(
(AH2 Gross)
(AH Gross)
attach documentation
Adjustments - Describe and
7.
a.
$
b.
$
8.
Net Taxable Arizona Premiums
$
(line 6+/ - line 7a +/- line 7b)
(AH2 Tax)
(AH Tax)
9.
Tax Rate
2%
10.
Tax Due
$
(line 8 x line 9)
(AHT)
E-PPD (12/00)
STATE OF ARIZONA
PAGE 2 of 3
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