Form E-Qtr - Ahcccs Contractor Quarterly Premium Tax Report
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1
2DEPARTMENT OF INSURANCE
AHCCCS CONTRACTOR
Reset
STATE OF ARIZONA
QUARTERLY PREMIUM TAX REPORT
InsuranceTax Unit
CALENDAR YEAR ______
th
2910 North 44
Street, Suite 210
Phoenix, Arizona 85018-7269
TC 1
Phone: (602) 364-3997
ORIGINAL REPORT
Fax: (602) 364-3989
TC 2
SUPPLEMENTAL REPORT
AHCCCS Contractor’s Complete Name
Federal I.D. Number
Preparer’s Name and Title
E-Mail Address
Toll-free or Collect Phone Number
Phone Number
Fax Number
You are required to file this report and pay estimated premium taxes on or before each DUE DATE
shown below. ARS §§ 36-2905 and 36-2944.01. See Form E-QTR.INSTRUCTION for further assistance.
1. CHECK ONE BOX TO IDENTIFY THE QUARTER FOR WHICH THIS REPORT IS FILED
OFFICE USE
DUE DATE FOR TAX
ONLY
CHECK
FOR CONTRACTOR CAPITATION IN:
REPORT AND
ONE
PERIOD
PAY
PAYMENT
CODE
CODE
TAX
QUARTER 1: January 1 through March 31
March 15
1
74
PAYMENT
DUE DATES
QUARTER 2: April 1 through June 30
June 15
4
76
QUARTER 3: July 1 through September 30
September 15
19
78
QUARTER 4: October 1 through December 31
December 15
20
79
2.
ENTER THE AHCCCS PLAN I.D. NUMBER AND ESTIMATED AMOUNT OF TOTAL CAPITATION,
including reinsurance and any other reimbursement paid to you by the Arizona Health Care Cost
Containment System for this quarter for each plan type.
AHCCCS Plan Types
Enter Plan I.D. Number
Enter Estimated Amounts
Acute Care
$
Ventilator Dependent
$
Elderly & Physically
$
Disabled
$
0.00
LINE 2 TOTAL
QT
0.00
PREMIUM TAX DUE = 2% (0.02) of LINE 2 TOTAL amount above
$
3.
4.
CIVIL PENALTY AND INTEREST: Your payment by check must be mailed, or your electronic payment via
the NAIC OPTins system must be submitted on or before the DUE DATE.
If PREMIUM TAX DUE on line 3 is paid after the DUE DATE, complete lines 4a, b and c:
4.a
Late Payment Penalty = 5% (0.05) of Line 3 or $25, whichever is greater
$
4.b
$
Interest = Line 3 x 1% (0.01) for each full/partial month that your payment is late
4.c
$
0.00
Total Penalty and Interest Due: Line 4a + 4b
26
0.00
5.
$
PRIOR QUARTER ADJUSTMENT
ATTACH PAGE 2 IF AN AMOUNT IS ENTERED
0.00
6.
TOTAL PAYMENT DUE: Sum of lines 3, 4c and 5
$
To electronically file tax reports and pay taxes via the NAIC OPTins system, visit the NAIC Web
site at , or call (816) 783-8990
To pay by check, make your check payable to Arizona Department of Insurance and mail it with
this form to the address at the top of this form.
E-QTR (REV. 09/10)
P
1
2
AGE
OF
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