2004 Annual Tax And Fees Report - Department Of Insurance State Of Arizona Page 2
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1
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3Company Name:
NAIC # ______________
PART A – 2004 ARIZONA PREMIUM TAX COMPUTATION
IMPORTANT! Attach copies of Schedule T and Arizona Business Page from 2004 Annual Statement
Total Arizona Premiums includes policy membership, other fees and all other considerations for insurance from all classes of insurance whether designated as a premium or otherwise received on accounts of policies
and contracts after deducting applicable cancellations, returned premiums, policy dividends, refunds, savings coupons and other similar returns paid or credited to policyholders and not reapplied as premiums for new,
additional or extended insurance.
Property/Casualty; Mortgage Guaranty; Prepaid Legal; Risk Retention
Life/Disability Insurers
Column 1
Group
Column 2
1.
1.
Arizona Life Premiums from Schedule T
$
Arizona Workers’ Compensation Premiums
$
(AZ State Page 20, line 16, Column 1)
(LI Gross)
(WC Gross)
Less Deductions:
Less Deductions:
a) Paid in cash or left on deposit
(-) $
a) (Specify)
(-) $
0.00
2.
b) Applied to pay renewal premiums (Only if included in line 1)
(-) $
Taxable Workers’ Compensation Premiums (line 1 minus 1a)
$
(WC TAX)
3.
4.5 %
c) Other (Describe and document)
(-) $
Tax Rate
0.00
0.00
2.
4.
Taxable Life Premiums (line 1 minus 1a, 1b, and 1c)
$
Workers’ Compensation Tax Due (line 2 x line 3)
(LI Tax)
3.
2%
5.
Tax Rate
Arizona Fire Tax Due from Form Sch-AFP (Line G, sum of Columns 1 & 3)
$
(FT)
0.00
4.
6.
Life Tax Due (line 2 x line 3)
$
Arizona Accident & Health Premiums
(AZ State Page 20, lines 13 thu 15.7, Col 1)
$
(LT)
(AH Gross)
(AN Gross)
5.
Arizona Annuity Considerations from Schedule T
$________________________
a) Less: Dividends Paid or Credited on Direct Business
(-) $
(AN Tax = 0)
Arizona Accident & Health Premiums from Life, A&H Sch T, line
(FE Gross)
6.
3, Column 4 or Health Sch T, line 3, sum of Columns 3, 4, 5 & 6)
$
b) Less: Federal Employee Health Benefit Plan Premiums (See Note 1 below)
(-) $
(FE Tax = 0)
(AH Gross)
c) Less: Exempt Accountable Health Plan Small Group (See Note 2 Below)
a) Less: Dividends Paid or Credited on Direct Business
(-) $
ATTACH FORM E-AHP
(-) $
b) Less: Federal Employee Health Benefit Plan Premiums (See
(FE Gross)
Note 1 below)
(-) $
d) Less: Other Deductions (Describe and document)
(-) $
(FE Tax = 0)
c) Less: Exempt Accountable Health Plan Small Group (See Note
0.00
7.
2 Below) ATTACH FORM E-AHP
(-) $
Taxable Accident & Health Premiums (line 6 minus 6 a through 6d)
$
(AH Tax)
8.
2%
d) Less: Other Deductions (Describe and document)
(-) $
Tax Rate
0.00
0.00
7.
9.
Taxable Accident & Health Premiums (line 6 minus 6a through 6d)
$
Accident & Health Tax Due (line 7 x line 8)
$
(AH Tax)
(AHT)
8.
2%
10.
Tax Rate
All Other Property & Casualty Premiums (See Note Below)
$
(PC Gross)
0.00
NOTE: Annual Statement Arizona State Page 20, column 1, line 34 plus Finance
9.
Accident & Health Tax Due (line 7 x line 8)
$
(AHT)
and Service Charges, minus line 1 above, minus line 6 above, and minus any
0.00
premiums segregated and subject to Fire Tax ONLY on Form Sch-AFP. Less
10.
Add lines 4 and 9 (Carry this Amount to Sch-RT Column C, line 9)
$
(GT)
deductions, excluding amounts already deducted from Workers’ Compensation,
Fire, and Accident and Health Premiums above.
a) Less: FCIC Reinsured Crop Hail (Attach Affidavit)
(-) $
(FC)
A.R.S.§ 20-2301 et seq ACCOUNTABLE HEALTH PLAN ACTIVITY IN CALENDAR YEAR 2004
b) Less: Other Deductions (Describe and document)
(-) $
Complete if claiming Exempt Accountable Health Plan Small Group Premiums in either Column 1, line 6b or
0.00
11.
Taxable Property & Casualty Premiums (line 10 minus 10a and 10b)
$
Column 2, line 6b on this page.
(PC TAX)
1. Number of Health Benefit Plans issued to small employers with 2, but not
12.
2%
more than 50 eligible employees
#
Tax Rate
(50P)
0.00
13.
#
Property & Casualty Tax Due (line 11 x line 12)
$
2. Number of lives covered by the Health Benefits Plan on line 1
(50L)
(PCT)
N
1:
Exempt Federal Employee Health Benefit Plan premiums must be reported in Line 6, Column 1 or Column 2 and
OTE
14.
Additional Vehicle Tax Due from Form Sch-AVP, line G
$
deducted in Line 6b of Column 1 or Column 2, respectively.
0.00
15.
N
2:
T
amount reported in Line 6c, Column 1 or Column 2 must be supported with a completed Form E-AHP.
Add lines 4, 5, 9, 13, and 14 (Carry this Amount to Sch-RT Column C, line 9)
$
OTE
HE
E-ANNUALTAX (12/04)
PAGE 2 OF 3
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