Annual Fees Report Form - 2007 - Department Of Insurance State Of Arizona
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1Department of Insurance
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State of Arizona
Financial Affairs Division – Tax unit
ANNUAL FEES REPORT
2910 North 44th Street, Suite 210
Phoenix, AZ 85018-7269
Telephone: (602) 364-3998
Facsimile: (602) 364-3989
This form is to be used by the company types listed below only. DO NOT file this form if your company
type is not listed. To confirm your company type, call (602) 364-3999 and provide your NAIC Number.
ANNUAL
STATEMENT
CERTIFICATE
TOTAL
COMPANY TYPE
FEE
RENEWAL FEE
FEES
DUE DATE
ACCREDITED REINSURER
$300
$135
$435
March 1
DOMESTIC LIFE & DISABILITY REINSURER
$300
$4500*
$4,800
March 31**
DOMESTIC MECHANICAL REIMBURSEMENT
REINSURER
n/a
$4500*
$4,500
April 1
DOMESTIC TITLE INSURER
$300
$135*
$435
March 31**
FOREIGN TITLE INSURER
$300
$135*
$435
March 1**
QUALIFIED REINSURER TRUST or QUALIFIED
REINSURER BASED ON SURPLUS
$300
n/a
$300
February 28
*If you do not pay your Certificate of Authority Renewal Fee by the due date we may summarily suspend
your Arizona Certificate of Authority. ARS § 20-217(E).
**If any of your fees are paid late, a penalty fee of up to $25 per day may be assessed. ARS § 20-223(D).
To pay by check, mail the form below with your check payable to the Arizona Department of Insurance. For
ACH credit payment, mark the box at the bottom of the form and see Form E-ACH.INSTRUCITON.
-----------------------------------------------------------------------------------------CUT OR TEAR HERE---------------------------------------------------------------------
ARIZONA DEPARTMENT OF INSURANCE
ANNUAL FEES REPORT
Fold so that address appears in window and mail to:
**** IMPORTANT ****
Arizona Department of Insurance
DO NOT SEND THIS FORM OR A CHECK
Financial Affairs Division – TAX UNIT
IN YOUR ANNUAL STATEMENT FILING
th
2910 North 44
Street Suite 210
PACKAGE OR WITH ANY OTHER FORMS
Phoenix, Arizona 85018-7269
Complete Company Name
PRINT/TYPE Preparer’s Name and Title
NAIC #
State of Incorporation
Phone
Fax
E-Mail Address
“X” THE BOX NEXT TO YOUR COMPANY TYPE AND PAY TOTAL FEES AMOUNT BY DUE DATE SHOWN
DUE
TOTAL
PC
OTHER
“X”
COMPANY TYPE
DATE
FEES
28
CODE / $
ACCREDITED REINSURER
3/1
$
435
300
58 / 135
DOMESTIC LIFE & DISABILITY REINSURER
3/31
$
4,800
300
57 / 4500
DOMESTIC MECHANICAL REIMBURSEMENT
REINSURER
4/1
$
4,500
n/a
65 / 4500
DOMESTIC TITLE INSURER
3/31
$
435
300
58 / 135
FOREIGN TITLE INSURER
3/1
$
435
300
58 / 135
QUALIFIED REINSURER TRUST or QUALIFIED
REINSURER BASED ON SURPLUS
2/28
$
300
300
n/a
MARK ONE BOX:
Check payable to the Arizona Department of Insurance is enclosed.
ACH credit delivery will be sent (see Form E-ACH.INSTRUCTION).
E-ANNUALFEES (12/07)
P
1
1
AGE
OF
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