Form Sch-Rt - Retaliatory Taxes And Fees Worksheet
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1
2Department of Insurance
Reset
State of Arizona
Financial Affairs Division – Tax unit
RETALIATORY TAXES
2910 North 44th Street, Suite 210
AND FEES WORKSHEET
Phoenix, AZ 85018-7269
Telephone: (602) 364-3998
Facsimile: (602) 364-3989
COMPANY NAME:
State Of Incorporation:
NAIC#:
YEAR:
FOREIGN AND ALIEN INSURERS MUST FILE THIS FORM WITH FORM E-ANNUALTAX
In the State of Incorporation Column, enter the amounts that a like Arizona insurer was required to pay to your state of
incorporation, using your Arizona business as the base amount for fees, assessments and taxes imposed. In the Arizona
column, enter only amounts you actually paid in the YEAR specified above. CALL THE TAX UNIT IF YOU NEED ASSISTANCE
WITH THIS SCHEDULE
Part 1: TAXES
A
TTACH SUPPORTING DOCUMENTATION FOR ALL DEDUCTION AMOUNTS REPORTED
TYPE OF
GROSS
DEDUCTIONS
(A)
TAX
(B)
(C)
INSURANCE
PREMIUMS
TAXABLE
RATE
ARIZONA
STATE OF
(Including Finance
PREMIUMS
INCORPORATION
& Service
Charges)
0.00
0.00
xxxxxxxxxxxxxxx
1
Life
$
$ (
)
$
% $
0.00
0.00
xxxxxxxxxxxxxxx
% $
2
Annuity
$
$ (
)
$
0.00
0.00
xxxxxxxxxxxxxxx
% $
3
Accident & Health
$
$ (
)
$
0.00
0.00
xxxxxxxxxxxxxxx
% $
4
Property & Casualty
$
$ (
)
$
Workers’
xxxxxxxxxxxxxxx
0.00
0.00
% $
5
$
$ (
)
$
Compensation
0.00
0.00
xxxxxxxxxxxxxxx
% $
6
Fire Marshal Tax
$
$ (
)
$
0.00
0.00
xxxxxxxxxxxxxxx
% $
7
Other:
$
$ (
)
$
0.00
0.00
xxxxxxxxxxxxxxx
% $
8
Other:
$
$ (
)
$
0.00
9 Subtotal #1 Column B: Enter sum of lines 1 through 8
0.00
$
XXXXXX $
$
Column C: Enter sum of amounts on line 7 in Form E-ANNUALTAX
Part 2: FEES
A
/
TTACH COPIES OF PAYMENTS AND
OR SUPPORTING SCHEDULES FOR EACH ITEM REPORTED
10
Certificate of Authority renewal fee. Risk Retention Group enter $0 in col C, ALL others enter $135
$
$
11
Annual Statement filing fee.
Risk Retention Group enter $0 in col C – ALL others enter $300 $
$
xxxxxxxxxxxxxxx
12
Publication fees.
[ A
]
$
TTACH INVOICE
xxxxxxxxxxxxxxx
13
Policies, rates and forms filing fees
$
14
Agent fees. IF APPLICABLE, attach
Form E-AZ AGENTS
and enter TOTALS from Part III, Line J
$
$
17
Other fees (filing articles, bylaws, amendments)
$
$
0.00
0.00
18
Subtotal #2 (Add lines 10 through 17)
$
$
PART 3: ASSESSMENTSA
/
TTACH COPIES OF PAYMENTS AND
OR SUPPORTING SCHEDULES FOR EACH ITEM REPORTED
19
Fraud Fund
[ A
D
]
$
$
TTACH
OCUMENTATION
xxxxxxxxxxxxxxx
20
Fraudulent Claims
California insurers - enter # of AZ vehicles
#
$
xxxxxxxxxxxxxx
21
Arizona Health Care Appeals Fund
[ A
D
]
$
TTACH
OCUMENTATION
xxxxxxxxxxxxxx
22
Arizona Fund for Voluntary Plans
[ A
D
]
$
TTACH
OCUMENTATION
xxxxxxxxxxxxxx
23
Arizona Auto Theft Authority
[ A
D
]
$
TTACH
OCUMENTATION
24
Other State of Incorporation Assessments
[ A
D
]
$
$
TTACH
OCUMENTATION
0.00
0.00
25
Subtotal #3 (Add lines 19 through 24)
$
$
PART 4: OTHER TAXES A
/
TTACH COPIES OF PAYMENTS AND
OR SUPPORTING SCHEDULES FOR EACH ITEM REPORTED
xxxxxxxxxxxxxxx
26
State income tax paid/payable for this tax year
[ A
P
-F
R
]
$
TTACH
RO
ORMA
ETURN
xxxxxxxxxxxxxxx
27
State income tax credit against premium tax for this tax year
$ (
)
xxxxxxxxxxxxxxx
28
State franchise tax paid/payable for this tax year
[ A
P
-F
R
]
$
TTACH
RO
ORMA
ETURN
xxxxxxxxxxxxxxx
29
State franchise tax credit against premium tax for this tax year
$ (
)
xxxxxxxxxxxxxxx
30
Local/Regional Tax -
If domiciled in AL, FL, GA, IL, KY, LA, MO, NE, NY, PA, SC, WV Attach Page 2
$
xxxxxxxxxxxxxxx
31
Fire Marshal/Fire District taxes (not reported above in Part 1)
$
xxxxxxxxxxxxxxx
32
Other State of Incorporation taxes
[ A
D
]
$
TTACH
OCUMENTATION
0.00
33
Subtotal # 4 (Add lines 26 through 32)
$
$0.00
0.00
0.00
34
RETALIATORY WORKSHEET TOTALS (Sum of Subtotal lines 9, 18, 25, 33)
(DOM) $
$
0.00
35
Total of Arizona column C, line 34.
$
Retaliatory Amount Due (column B, line 34 minus line 35) If result is less than zero, enter "0".
0.00
36
(RT)
Carry this amount to Form E-ANNUALTAX, Page 1, Part C, line 1.
$
Sch-RT (Rev.12/08)
ARIZONA DEPARTMENT OF INSURANCE
PAGE 1 OF 2
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