2004 Annual Tax And Fees Report - Department Of Insurance State Of Arizona
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1
2
3DEPARTMENT OF INSURANCE
STATE OF ARIZONA
FINANCIAL AFFAIRS DIVISION - TAX UNIT
th
2910 North 44
Street, Suite 210
Phoenix, Arizona 85018-7256
Phone: (602) 912-8429 Fax: (602) 912-8421
LIFE & DISABILITY
PROPERTY & CASUALTY
MORTGAGE GUARANTY
PREPAID LEGAL
RISK RETENTION
INSURER
INSURER
INSURER
INSURER
GROUP
NOTE: All Insurers other than HCSO’s, Service Corporations or Prepaid Dental Plan Organizations filing the Health Annual
Statement must use this tax report form.
2004 ANNUAL TAX AND FEES REPORT
DUE MARCH 1, 2005
ORIGINAL REPORT
__________________________________________________________________________________________
AMENDED REPORT / REASON
Complete Company Name and Home Office Address
State of Incorporation
X
X
X
NAIC Number
X
NAIC Group Number
X
Federal I. D. Number
Preparer’s Name and Title:
E-Mail Address:
Toll Free or Collect Phone:
FAX:
Complete Mail Address:
PART C – SUMMARY OF TAXES AND FEES DUE
1) Retaliatory Amount – Foreign or Alien Insurers and Risk Retention Groups Only
$
(Sch-RT, Page 1, column B, line 36 , not less than zero)
(Pay Code 04)
0.00
$
2) Premium Tax (Part B, Page 3, Column 1, Line 8a or Column 2, Line 10a - not less than zero)
Certificate of Authority Renewal Fee
0.00
3)
Foreign or Alien Risk Retention Group Only – Not applicable
ENTER ONLY ONE FEE ON LINE A
$
(a)
a Domestic STOCK Life/Disability Insurer Only ENTER $1,500.00
(Pay Code 56)
OR LINE B. Failure to pay fee will
$
(b)
result in license suspension.
b ALL OTHER INSURERS………………….MUST ENTER
$135.00
(Pay Code 58)
4) Annual Statement Filing Fee
0.00
Foreign or Alien Risk Retention Group Only – Not applicable
INSURER OTHER THAN RISK RETENTION
$
ALL OTHER INSURERS………………….MUST ENTER
$300.00
(Pay Code 28)
GROUP MUST ENTER AND PAY THIS FEE
0.00
$
5) TOTAL DUE March 1 (Sum of lines 1, 2, 3a or b as applicable and 4 as applicable)
PAYMENT OPTIONS –
ONLY ONE
:
CHECK
OPTION FOR REMITTANCE OF THE AMOUNT DUE ABOVE
-
.
ACH DELIVERY IN ACCORDANCE WITH THE FORMAT AND CONTENT PRESCRIBED IN FORM E
ACH
INSTRUCTION
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I
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S
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A
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IS ENCLOSED WITH THIS REPORT.
CHECK PAYABLE TO
MAIL THIS REPORT TO:
Attention: TAX UNIT
ARIZONA DEPARTMENT OF INSURANCE
2910 North 44
Street, Suite 210
th
Phoenix, Arizona 85018-7256
PREPARER CERTIFICATION
COMPANY OFFICER CERTIFICATION
I certify that I have prepared this report. It is true, complete and correct to the
I certify that I have examined this report. It is true, complete and correct to the best
best of my knowledge.
of my knowledge.
SIGNATURE OF PREPARER
DATE
SIGNATURE OF OFFICER
DATE
NAME AND TITLE TYPED OR PRINTED
NAME AND TITLE TYPED OR PRINTED
E-ANNUALTAX (12/04)
PAGE 1 OF 3
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