2004 Annual Tax And Fees Report - Arizona Department Of Insurance Page 2

Download a blank fillable 2004 Annual Tax And Fees Report - Arizona Department Of Insurance in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete 2004 Annual Tax And Fees Report - Arizona Department Of Insurance with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

COMPANY NAME

NAIC NO.

PART A – ARIZONA HEALTH BUSINESS

IMPORTANT - Attach copies of the ARIZONA State Page 30 and Schedule T from the 2004 Health Annual Statement to this page.

COMPREHENSIVE MEDICAL

MEDICARE

GRAND

Individual

AHP Small

All Other

Federal

Title XVIII Medicare

Medicare

Vision

Dental

Other

TOTAL

Group Only

Group

Employees

Funds Received from

Funds Received

Supplement

Only

Sum of Columns

Health

Federal Government

from Enrollees

B through K

Benefit Plan

Arizona Premium

Collected

(Annual

Statement Page 30,

line 12)

[AH Gross]

[GAH Gross]

[FE Gross/Tax = 0]

[MCX Gross/Tax = 0]

2. Exempt

Premiums (See

Below)

AZ Premium

Subject to

Premium Tax at

(line 1 minus

line 2)

XXXXXXXXXXX

XXXXXXXXXXXX

XXXXXXXXXX

[AH Tax]

[GAH Tax]

4. Tax Rate

Gross Tax Amount

ACCOUNTABLE HEALTH PLAN ACTIVITY –

[AHT]

Complete if Accountable Health Plan Small Group premiums reported in Column C.

(line 3 x line 4)

Carry to Page 3, line 1

[50P]

1. Number of Health Benefit Plans issued to small employers with 2, but not more than 50 eligible employees

[50L]

2. Number of lives covered by the Health Benefits Plan on line 1

LINE 2 EXEMPTIONS

HOSPITAL, MEDICAL, DENTAL AND OPTOMETRIC SERVICE CORPORATIONS ONLY – Pursuant to A.R.S. § 20-837, “the tax shall not apply with respect to any coverage concerning which the corporation's relationship is

as administrative or fiscal agent for national, state or municipal government or any political subdivision or body thereof, and such tax shall not apply with respect to any premiums received from funds of national, state or municipal

government or any political subdivision or body thereof.” Complete Form E-HEALTHORG.HMDO and enter the exempt amounts in the appropriate Columns on line 2, including Column A.

HEALTH CARE SERVICES ORGANIZATIONS ONLY – Pursuant to A.R.S. § 20-1060, “Payments received by health care services organizations from the secretary of health and human services pursuant to a contract

issued pursuant to 42 United States Code section 1395mm(g) are not taxable…” Enter amounts in Columns F and A on line 2 for these exempt funds.

FEDERAL EMPLOYEE HEALTH BENEFIT PLAN premiums are pre-empted from state tax under federal law. Enter the full amount reported in line 1 of Column E on line 2 of Column E, and include the amounts in lines 1 and 2

of Column A.

COLUMN C, LINES 1 AND 2 – AHP SMALL GROUP ONLY:

This Column should only be completed if the organization is an approved Accountable Health Plan (“AHP”) that issued “Health Benefit Plans” to “Small Employers” pursuant to the definitions prescribed in A.R.S. § 20-2301.

THE ORGANIZATION MUST COMPLETE AND ATTACH FORM E-AHP TO SUPPORT THE CLAIMED EXEMPT PREMIUMS and provide “Accountable Health Plan Activity” information above.

E-HEALTHORG (R

. 12/04)

STATE OF ARIZONA

AGE