Form E-Sl-1 - Arizona Licensed Surplus Lines Broker Semi-Annual Statement And Premium Tax Report - 2007 Page 2

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ARIZONA SEMI-ANNUAL STATEMENT AND PREMIUM TAX REPORT JANUARY 1, 2007 THROUGH JUNE 30, 2007
Surplus Lines Broker_____________________________________ Arizona License Number
(Type exact name as on Arizona license)
PART A - EXHIBIT OF SURPLUS LINES INSURANCE BUSINESS TRANSACTED
Based on Policy Effective Date or Cancellation Effective Date*
Enter "0" or "None" Where Applicable – DO NOT FILE A BLANK STATEMENT OR A “NONE” REPORT
(A)
(D)
(B)
(C)
Aggregate Gross
Fire Portion of
Line of
Return
Aggregate
Premiums Charged
Aggregate
Business
Premiums
Net
Including Fees
Net Premiums
Description
Paid to Insureds
Premiums
0.00
$
(-)$
= $
Accident & Health
An amount must
0.00
appear in the box
$
(-)$
= $
Automobile Liability
below for Fire and
Allied Lines and
0.00
Automobile Physical
carried to total
$
(-)$
= $
Damage
lines
0.00
$
(-)$
= $
Aviation Liability
0.00
$
(-)$
= $
Aircraft Physical Damage
0.00
$
(-)$
= $
$
Fire and Allied Lines
▼
0.00
$
(-)$
= $
General Liability
▼
0.00
$
(-)$
= $
Inland Marine
▼
0.00
Miscellaneous Special
$
(-)$
= $
Lines
▼
0.00
$
(-)$
= $
Products
▼
Professional Liability and
0.00
$
(-)$
= $
Malpractice (Incl. E&O)
1. TOTAL EACH
0.00
0.00
0.00
COLUMN
$
(-)$
= $
$
[SL Gross]
[SLF Gross]
2. EXEMPT PREMIUMS –
ATTACH LIST IDENTIFYING EACH INSURED,
0.00
0.00
(-)$
(-)$
AMOUNTS AND BASIS OF EXEMPTION
[SLX ]
3. TOTAL SURPLUS LINES PREMIUMS SUBJECT TO TAX
0.00
0.00
–
= $
= $
SUBTRACT LINE 2 FROM LINE 1 IN COLUMNS C AND D
[SL Taxable]
[SLF Taxable}
3 %
SURPLUS LINES TAX RATE
IF LINE 4 IS NEGATIVE,
FORM E-173SLB CLAIM FOR
0.00
REFUND MUST BE
4. SURPLUS LINES PREMIUM TAX DUE -
$
LINE 3, COLUMN C times 0.03
ATTACHED
ATTACH THIS PAGE AND ANY SUPPORTING SCHEDULES TO PAGE 1
*Report must reflect all new, renewal and cancellation transactions with effective dates that fall in this Semi-Annual period.
Transactions reported to the Surplus Lines Association of Arizona more than 60 days after the policy effective date or
cancellation effective date may require you to file Form E-SL-AMEND for a prior period to be promptly filed with this
Department with payment of any additional tax due. Call (602) 364-3998 for assistance.
E-SL-1 (R
. 6/07)
P
2
2
EV
AGE
OF

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