Unaffiliated Credit Life & Disability Reinsurer Annual Fees Report Form - Department Of Insurance - Arizona

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Department of Insurance
UNAFFILIATED CREDIT LIFE &
State of Arizona
DISABILITY REINSURER
Financial Affairs Division – Tax unit
ANNUAL FEES REPORT
Telephone: (602) 364-3998
FOR CALENDAR YEAR _______
Facsimile: (602) 364-3989
YOU MUST FILE THIS REPORT AND PAY FEES BY:
AUGUST 1* IF YOUR FISCAL YEAR ENDS 12/31
OR
NOVEMBER 1* IF YOUR FISCAL YEAR END IS NOT 12/31
YOU DO NOT NEED TO FILE THIS REPORT IF YOU PAY YOUR FEES BY ACH CREDIT. SEE
FORM E-ACH.INSTRUCTION.
Complete Company Name and Home Office Address
State of Incorporation
X
X
ARIZONA
X
Arizona Company Number:
X
Federal I. D. Number:
X
E-Mail Address:
Complete Mail Address:
Preparer’s Name and Title:
Toll Free or Collect Phone:
Phone:
FAX:
Annual Fees Due:
1)
Certificate of Authority Renewal Fee
$ 4,500.00
(Pay Code 57)
2)
Annual Statement Filing Fee
$
300.00
(Pay Code 28)
3)
$ 4,800.00
TOTAL ANNUAL FEES DUE
M
: ARIZONA DEPARTMENT OF INSURANCE
AKE YOUR CHECK PAYABLE TO
You must send your payment by check WITH this Report by the Due Date. We extend the Due Date to the
next business day when it falls on a Saturday, Sunday or State holiday.
OUR "POSTMARK POLICY": Your package or envelope must have a valid postmark by the United States
Postal Service* on it, or your package sent by courier service must show the date of the courier pick-up. If your
package does not show proof that it was mailed on or before the due date, it will be considered late. *Postage
meter stamps do not qualify as a postmark.
WE MAY CHARGE YOU LATE PENALTY FEES UP TO $25 FOR EACH DAY YOUR FEES ARE LATE. ARS
§ 20-223(D).
WE MAY SUMMARILY SUSPEND YOUR ARIZONA CERTIFICATE OF AUTHORITY IF YOU FAIL TO PAY
THE CERTIFICATE OF AUTHORITY RENEWAL FEE WHEN IT IS DUE. ARS § 20-217(E).
DO NOT MAIL THIS FORM OR YOUR PAYMENT IN YOUR ANNUAL STATEMENT PACKAGE.
YOU MUST MAIL THIS FORM AND YOUR PAYMENT TO:
ATTN: TAX UNIT
ARIZONA DEPARTMENT OF INSURANCE
TH
2910 NORTH 44
STREET, SUITE 210
PHOENIX, AZ 85018-7269
E-UCLDR (R
. 05/08)
P
1
1
EV
AGE
OF

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