Annual Fees Report - Department Of Insurance
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1Department of Insurance
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State of Arizona
ANNUAL FEES REPORT
Financial Affairs Division – Tax Unit
2910 North 44th Street, Suite 210
Phoenix, AZ 85018-7269
YEAR _________
Telephone: (602) 364-3997
Facsimile: (602) 364-3989
This form is for 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 or use our Look Up
feature at
“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 / $
$ 435
ACCREDITED REINSURER
3/01
300
58 / 135
DOMESTIC LIFE & DISABILITY REINSURER
3/31
$ 4,800
300
57 / 4500
DOMESTIC MECHANICAL REIMBURSEMENT
REINSURER
4/01
$ 4,500
n/a
57 / 4500
DOMESTIC TITLE INSURER
3/31
$ 435
300
58 / 135
FOREIGN TITLE INSURER
3/01
$ 435
300
58 / 135
QUALIFIED REINSURER TRUST or QUALIFIED
REINSURER BASED ON SURPLUS
2/28
$ 300
300
n/a
Complete Company Name and Mail Office Address
State of Incorporation
X
X
X
NAIC Number:
X
Federal I. D. Number:
X
E-Mail Address:
Preparer’s Name and Title:
Preparer’s Mail Address:
Preparer’s Toll Free/Collect Phone:
Phone:
FAX:
You can no longer pay fees by ACH credit.
You can electronically pay fees using the NAIC
OPTins system.
Do not file this form if you pay your fees via the NAIC OPTins system.
To pay by check make your check payable to Arizona Department of Insurance and mail it with
this form to the address above.
IMPORTANT: DO NOT MAIL THIS FORM OR YOUR PAYMENT INSIDE YOUR ANNUAL
STATEMENT PACKAGE. MAIL YOUR CHECK WITH THIS REPORT SEPARATELY, ATTENTION
TAX UNIT TO THE ADDRESS ABOVE.
We may summarily suspend your Arizona Certificate of Authority if you do not pay your
Certificate of Authority Renewal Fee by the due date. ARS § 20-217(E).
We may assess a penalty fee of up to $25 per day if you pay fees late. ARS § 20-223(D).
E-ANNUALFEES (1/09)
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1
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