Annual Fees Report Form - Department Of Insurance

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DEPARTMENT OF INSURANCE
STATE OF ARIZONA
ANNUAL FEES REPORT
Financial Affairs Division- Tax Unit
th
2910 North 44
Street, Suite 210
Phoenix, Arizona 85018-7269
YEAR _________
Phone: (602) 364-3997 | Fax: (602) 364-
Reset
3989
ORIGINAL REPORT
AMENDED REPORT / REASON__________________________________
File this form only if you operate in Arizona as a business type listed below. To confirm your business
type in Arizona, search for your record on our web site at
To pay your fees electronically:
Use the NAIC OPTins system. For information about OPTins:
•
Visit the NAIC Web site at
•
Contact the OPTins Help Desk at
or (816) 783-8990
Note: To use OPTins, you must establish an account and electronic funds transfer protocol with the
NAIC, which can take up to two weeks. DO NOT submit this form if you use OPTins.
To pay by check:
•
Complete this form and mail it with your check.
•
Make your check payable to Arizona Department of Insurance, print your NAIC number in the
memo section. DO NOT mail this form or payment with your annual statement.
NOTE: If we do not receive your fee by or before the due date, we may require you to pay a penalty
and we may summarily suspend your certificate of authority. ARS §§ 20-217(E), 20-223(D).
DUE
TOTAL
PC
OTHER
BUSINESS TYPE (Check the applicable box)
DATE
FEES
28
CODE / $
ACCREDITED REINSURER
3/01
$ 435.00
300
58 / 135
DOMESTIC LIFE & DISABILITY REINSURER
3/31
$ 4,800.00
300
57 / 4500
DOMESTIC MECHANICAL REIMBURSEMENT
REINSURER
4/01
$ 4,500.00
n/a
57 / 4500
DOMESTIC TITLE INSURER
3/31
$ 435.00
300
58 / 135
FOREIGN TITLE INSURER
3/01
$ 435.00
300
58 / 135
QUALIFIED REINSURER TRUST or
QUALIFIED REINSURER BASED ON SURPLUS
2/28
$ 300.00
300
n/a
COMPANY INFORMATION
Complete Name of Company
NAIC #
State of Domicile
FEIN
Mailing Address
City
State
ZIP Code
PREPARER INFORMATION
Name of Preparer
Title
Preparer’s Mailing Address
City
State
ZIP Code
Toll-free Phone Number
Fax Number
E-mail Address
E-ANNUALFEES (11/09)
P
1
1
AGE
OF

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