Schedule Rt - Section C - Wisconsin Related Entity Expenses Disclosure Statement
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1For the year ended December 31,
2010
<Enter the Insurer's Name>
<Domicile>
<NAIC#>
SCHEDULE RT
APPOINTMENT FEES: SKIP this APPOINTMENT FEES section if the insurer is domiciled in one of the following states:
Alaska, California, Colorado, Connecticut, Hawaii, Idaho, Illinois, Indiana, Iowa, Maryland, Missouri, Montana,
New York, Oregon, Texas, Utah or Vermont.
IMPORTANT NOTES REGARDING NUMBER OF APPOINTMENTS.
The District of Columbia (DC), Kentucky (KY), Louisiana (LA), New Mexico (NM), North Carolina (NC) and Virginia (VA)
require insurers to submit one appointment fee for each line of authority that the insurer authorizes the producer to sell,
solicit or negotiate. Therefore, for “Number of new appointments during the calendar year” and “Number of appointments
renewed during the calendar year,” insurers domiciled in DC, KY, LA, NM, NC and VA must enter the sum of the lines of
authority for all Arizona-licensed insurance producers that the insurer uses to sell, solicit or negotiate in Arizona.
Otherwise, the numbers that you enter for “Number of new appointments during the calendar year” and “Number of
appointments renewed during the calendar year” must represent the number of Arizona insurance producers (including
individuals and business entities) who sold, solicited or negotiated insurance for the insurer during the calendar year.
[1]
[3]
Number of new
[2]
Total fees for new
appointments during the
Appointment fee in
appointments
PRODUCER APPOINTMENTS
calendar year
domicile
([1] X [2])
Arizona-resident insurance producer
individuals
0.00
Arizona-resident insurance producer
business entities
0.00
Arizona non-resident insurance
producer individuals
0.00
Arizona non-resident insurance
producer business entities
0.00
COLUMN [3] TOTAL:
0.00
[4]
[6]
Number of appointments
[5]
Total fees for
renewed during the
Appointment renewal
appointment
PRODUCER APPOINTMENT
RENEWALS
calendar year
fee in domicile
renewals ([4] X [5])
Arizona-resident insurance producer
individuals
0.00
Arizona-resident insurance producer
business entities
0.00
Arizona non-resident insurance
producer individuals
0.00
Arizona non-resident insurance
producer business entities
0.00
COLUMN [6] TOTAL:
0.00
PRODUCER TERMINATIONS
[7]
[8]
[9]
Number of Appointment
Appointment
Total termination
(complete only if insurer is domiciled in
Terminations
Termination Fee
fees ([7] X [8])
AR, CA, NE, NH, NJ, NC, TN, or WY)
Arizona resident and nonresident
insurance producer individuals
0.00
Arizona resident and nonresident
insurance producer business entities
0.00
COLUMN [9] TOTAL:
0.00
C.
Appointment fees total - enter the sum of Column [3] + Column [6] + Column [9]:
0.00
____________________
RETALIATION: Appointment Fees
E-TAX-RT-C (v. 2011032 )
Prepared 3/22/2011
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