Form Efees-I-Application Fees Worksheet June 2000
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1Department of Insurance
State of Arizona
Financial Affairs Division
2910 NORTH 44TH STREET, SUITE 210
Phoenix, Arizona 85018-7256
Telephone: (602) 912-8420
Telecopier: (602) 912-8421
APPLICATION FEES WORKSHEET
FORM EFEES-I
USE
FOR INSTRUCTIONS AND ARIZONA FEES INFORMATION
Applicant Name:
State of Domicile or Entry:
NAIC#:
Federal ID#:
Part A - Customary Application Fees
Arizona Fees
Domicile Fees
Application Fee
$ None
$
Charter Documents Filing Fee:
$_____________
$
Initial -
[Code 35]
$_____________
$
Amended
- [Code 36]
Annual Statement Filing Fee -
$_____________
$
[Code 28]
Certificate of Authority Fee -
$_____________
$
[Code 64] [Code 1 - FB] [Code 2 - SC]
[Code 12 - HC] [Code 25 - LC] [Code 14 - MR] [Code 59 - CE]
Other Fees (Describe)
$ None
$
$ None
$
SUM OF PART A =
$_____________
$
Part B - Fingerprint Card Processing Fees
Enter totals based on amount per card times the number
$
$
of cards (@ 1 per individual) in the Application -
[Code 66]
Part C - Other Fees
Corporation Commission
$
$
Secretary of State
$
$
Recording/Publication Fees
$
$
Other Fees (Describe)
________________________________________
$ None
$
________________________________________
$ None
$
SUM OF PART C =
$_____________
$
Part D - TOTAL FEES: Sum of Parts A, B and C
$
$
If Domicile Total is GREATER THAN Arizona Total, complete Part E.
If Domicile Total is LESS THAN Arizona Total, carry the Sum of Part A, Arizona Fees column to Form
ETRANSMT for “Application Fees” payable to the Arizona Department of Insurance.
Part E - Retaliatory Fees Calculation
1) Enter Part D Domicile Fees column amount.....................................................................$
2) Enter sum of Parts B and C, Arizona Fees column ..........................................................$
3) Enter result of line 1 minus line 2 (not less than zero)....................................................$
4) Enter the greater of:
Sum of Part A, Arizona Fees column, OR Part E, Line 3 -
..............................$
[Code 04]
Carry the amount on Line 4 to Form ETRANSMT for “Application Fees” payable to the Arizona Department of
Insurance.
Type or Print Preparer’s Name and Title
Signature of Preparer
Date
Form EFEES (06/00)
Page 1 of 1
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