Form E-Healthorg - Health Organization Annual Tax And Fees Report - Department Of Insurance State Of Arizona

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Department of Insurance
State of Arizona
HEALTH ORGANIZATION
Financial Affairs Division – Tax unit
ANNUAL TAX AND FEES REPORT
2910 North 44th Street, Suite 210
Phoenix, AZ 85018-7269
DUE MARCH 1
Telephone: (602) 364-3998
Facsimile: (602) 364-3989
This tax report form must be filed by the following types of insurers ONLY:
HOSPITAL, MEDICAL, DENTAL AND
HEALTH CARE SERVICES
PREPAID DENTAL PLAN
OPTOMETRIC SERVICE
ORGANIZATION
ORGANIZATION
CORPORATION
ENTER THE CALENDAR YEAR OF THIS REPORT: _________
ORIGINAL REPORT
AMENDED REPORT / REASON: ____________________________________________________________________
Complete Company Name and Mail Office Address
State of Incorporation
X
X
X
NAIC Number:
X
Federal I. D. Number:
X
Preparer’s Name and Title:
E-Mail Address:
Preparer’s Mail Address:
Preparer’s Toll Free or Collect Phone:
Phone:
FAX:
PART C – SUMMARY OF TAXES AND FEES DUE
0.00
1)
Tax Due (Part B, Page 3, line 5a – not less than zero)
$
(Pay Code 07)
2)
Certificate of Authority Renewal Fee
$
75.00
(Pay Code 63)
3)
Annual Statement Filing Fee
$
300.00
(Pay Code 28)
375.00
4)
TOTAL DUE (Add lines 1 through 3) - NOT LESS THAN $375.00
$
MARK ONE BOX:
CHECK PAYABLE TO ARIZONA DEPARTMENT OF INSURANCE IS ENCLOSED.
ACH CREDIT DELIVERY WILL BE SENT (SEE FORM E-ACH.INSTRUCTIONS).
TAX REPORT PREPARER AND COMPANY OFFICER CERTIFICATION AND SIGNATURES (REQUIRED)
We certify that this report is true, complete and correct to the best of our knowledge.
SIGNATURE OF PREPARER
DATE
SIGNATURE OF OFFICER
DATE
NAME AND TITLE TYPED OR PRINTED
NAME AND TITLE TYPED OR PRINTED
E-HEALTHORG (R
. 12/07)
ARIZONA DEPARTMENT OF INSURANCE
P
1
3
EV
AGE
OF

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