Annual Tax And Fees Report Form - Arizona Department Of Insurance
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Department of Insurance
ANNUAL TAX AND FEES REPORT
State of Arizona
Financial Affairs Division – Tax Unit
DUE MARCH 1
2910 North 44th Street, Suite 210
Phoenix, AZ 85018-7269
ENTER THE CALENDAR YEAR OF
Telephone: (602) 364-3998
THIS REPORT _________
Facsimile: (602) 364-3989
This tax report form must be filed by the following types of companies:
FRATERNAL
LIFE &
PROPERTY &
MORTGAGE
PREPAID
RISK RETENTION
BENEFIT SOCIETY
DISABILITY
CASUALTY
GUARANTY
LEGAL
GROUP
(Page 1 only)
INSURER
INSURER
INSURER
INSURER
NOTE: HCSO’s, Service Corporations and Prepaid Dental Plan Organizations must file Form E-HEALTHORG
Title Insurers must file forms E-ANNUALFEES and E-TITLE.RETALIATORY
ORIGINAL REPORT
AMENDED REPORT / REASON
Complete Company Name and Home Office Address
State of Incorporation
X
X
X
NAIC Number:
X
Federal I. D. Number:
Preparer’s Name and Title:
E-Mail Address:
Preparer’s Toll Free or Collect Phone:
FAX:
Preparer’s Mail Address, if not above:
PART C – SUMMARY OF TAXES AND FEES DUE
1. Retaliatory Amount – Foreign or Alien companies ONLY
$
Enter the amount from Sch-RT, Page 1, column B, line 36 - not less than zero
04
0.00
2. Premium Tax – Enter the amount from Part B, Page 2, Line 16a - not less than zero
$
07
3.
Certificate of Authority
0.00
RISK RETENTION GROUP – NOT APPLICABLE
Renewal Fee
ARIZONA DOMESTIC STOCK LIFE AND
$
ENTER ONLY ONE FEE ON
a
56
DISABILITY INSURER
ENTER→ $1,500.00
LINE A, B OR C. Failure to
$
b
54
$30.00
FRATERNAL BENEFIT SOCIETY ENTER→
pay fee will result in license
$
c ALL OTHER INSURERS
58
suspension
ENTER→ $135.00
.
4. Annual Statement Filing Fee
0.00
RISK RETENTION GROUP – NOT APPLICABLE
ALL INSURERS EXCEPT RISK
RETENTION GROUPS MUST
$
28
ALL OTHERS
ENTER→ $300.00
ENTER AND PAY THIS FEE
0.00
5. TOTAL DUE March 1 – Enter the sum of lines 1, 2, 3a, b or c and 4, as applicable
$
MARK ONE BOX:
Check payable to the Arizona Department of Insurance is enclosed.
ACH credit delivery will be sent (see Form E-ACH.INSTRUCTION).
MAIL THIS REPORT TO:
Attention: TAX UNIT
ARIZONA DEPARTMENT OF INSURANCE
th
2910 North 44
Street, Suite 210
Phoenix, Arizona 85018-7269
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-ANNUALTAX (REV. 12/07)
Arizona Department of Insurance
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