2004 Annual Tax And Fees Report - Department Of Insurance State Of Arizona Page 3
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NAIC #
PART B - ARIZONA PREMIUM TAXES DUE FOR CALENDAR YEAR 2004
Life/Disability Insurers
Column 1
Property/Casualty; Mortgage Guaranty; Prepaid Legal; Risk Retention Group
Column 2
0.00
0.00
1.
1.
Life Tax from Part A, Page 2, Column 1, line 4
$
Arizona Fire Tax from Part A, Page 2, Column 2, line 5
$
(Code 09)
0.00
0.00
2.
2.
Accident & Health Tax from Part A, Page 2, Column 1, line 9
$
Accident & Health Tax from Part A, Page 2, Column 2, line 9
$
(Code 07)
0.00
0.00
3.
3.
Gross Arizona premium taxes (add lines 1 and 2, above)
$
Property & Casualty Tax from Part A, Page 2, Column 2, line 13
$
(Code 07)
0.00
4.
4.
Less Allowable Credits and Offsets:
Additional Vehicle Tax from Part A, Page 2, Column 2, line 14
$
(Code 05)
0.00
5.
a) Total Available Guaranty Fund Offsets (NONE IN 2004)
$ XXXXXXXXXXXXXXXXXX
Gross Arizona premium taxes (add lines 1 through 4 above)
$
(TGF)
(GT)
6.
b) Enterprise Zone Credits
$
Less Allowable Credits and Offsets:
[ A
F
E-Z
]
TTACH
ORM
ONE
(EZC)
c) Military Reuse Zone Credits
$
a) Total Available Guaranty Fund Offsets (NONE IN 2004)
$ XXXXXXXXXXXXXXXXXXXX
[ A
F
M-Z
]
TTACH
ORM
ONE
(MZC)
(TGF)
d) Domestic Stock Life/Disability ONLY $567.50
$
b) Enterprise Zone Credits
$
A.R.S. § 20-167(D)
[ A
F
E-Z
]
(SC)
TTACH
ORM
ONE
(EZC)
0.00
e) Total Credits and Offsets (add lines 4a through 4d)
$
c) Military Reuse Zone Credits
$
[ A
F
M-Z
]
(TAO)
TTACH
ORM
ONE
(MZC)
0.00
5.
Enter the LESSER amount of line 3 or line 4e
$
d) Total Credits and Offsets (add lines 6a through 6c)
$
(TC)
(TAO)
7.
Enter the LESSER amount of line 5 or line 6d
$
(TC)
6.
Total net Arizona premium taxes:
If line 3 is negative, enter the negative amount from line 3 with (-).
Total net Arizona premium taxes:
8.
(IB)
If line 3 is not negative, enter the result of line 3 minus line 5.
If line 5 is negative, enter the negative amount from line 3 with (-).
2005 Installment Tax Base ⇒
$
(IB)
If line 5 is not negative, enter the result of line 5 minus line 7.
7.
Less: 2004 Installment Taxes Paid (excluding penalty or interest)
2005 Installment Tax Base ⇒
$
$
9.
a) March 15, 2004
Less: 2004 Installment Taxes Paid (excluding penalty or interest)
$
b) April 15, 2004
a) March 15, 2004
$
$
c) May 15, 2004
b) April 15, 2004
$
d) June 15, 2004
$
c) May 15, 2004
$
e) July 15, 2004
$
d) June 15, 2004
$
f) August 15, 2004
$
e) July 15, 2004
$
0.00
g) Total of lines 7a through 7f
$
f) August 15, 2004
$
(TIP)
Enter result of line 6 minus line 7g on line 8a if positive, or on 8b if
0.00
8.
negative.
g) Total of lines 9a through 9f
$
(TIP)
(NT)
10.
a) Arizona premium tax due -carry to Part C, Page 1, line 2
$
Enter result of line 8 minus line 9g on line 10a if positive, or on 10b if negative.
*
(SR)
(NT)
b) Overpayment of Arizona premium taxes - to be refunded
$
a) Arizona premium tax due -carry to Part C, Page 1, line 2
$
*
(SR)
b) Overpayment of Arizona premium taxes - to be refunded
$
*
Warning! DO NOT ATTEMPT TO APPLY A PREMIUM TAX OVERPAYMENT TO RETALIATORY TAXES OR ANNUAL FEES DUE WITH THIS REPORT. OVERPAYMENTS WILL BE REFUNDED WITHIN 90 DAYS
OF THE DUE DATE OF THIS REPORT. ANNUAL FEES AND RETALIATORY TAX MUST BE PAID WITH THIS RETURN.
ALL FOREIGN AND ALIEN INSURERS MUST COMPLETE RETALIATORY FORM SCH-RT…… THEN CONTINUE TO PART C ON PAGE 1 FOR SUMMARY AND SIGNATURES
PENALTY FOR LATE PAYMENT OF TAX: Late Payment of tax is subject to a civil penalty equal to the greater of $25 or 5% of the tax paid late, plus interest of 1% per month from the date the tax was due.
E-ANNUALTAX (12/04)
PAGE 3 OF 3
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