Form E-Lr - Domestic Life & Disability Reinsurer Annual Fees Report - 2004
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1DEPARTMENT 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
DOMESTIC LIFE & DISABILITY REINSURER ANNUAL FEES REPORT
DUE MARCH 31*
*DO NOT FILE THIS REPORT IF THE TOTAL ANNUAL FEES WILL BE PAID BY ACH DELIVERY.
SEE FORM E-ACH.INSTRUCTION FOR DETAILS REGARDING THE ACH PAYMENT OPTION.
Complete Company Name and Home Office Address
State of Incorporation
X
X
ARIZONA
X
NAIC Number
X
NAIC Group Number
X
Federal I. D. Number
X
Preparer’s Name and Title:
E-Mail Address:
Toll Free or Collect Phone: (
)
FAX: (
)
Complete Mail Address:
Summary of Annual Fees Due March 31
1)
Certificate of Authority Renewal Fee
$
4,500.00
(Pay Code 57)
2)
Annual Statement Filing Fee
$
300.00
(Pay Code 28)
3)
TOTAL DUE MARCH 31
$
4,800.00
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AKE CHECK PAYABLE TO
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:
Attention: TAX UNIT
ND
AIL CHECK WITH REPORT TO
2910 North 44
Street, Suite 210
th
Phoenix, Arizona 85018-7256
FAILURE TO TIMELY PAY THE CERTIFICATE OF AUTHORITY FEE OR THE ANNUAL STATEMENT FILING FEE WILL
RESULT IN ASSESSMENT OF LATE PENALTY FEES OF UP TO $25 PER DAY PURSUANT TO § 20-223(D).
FAILURE TO PAY THE CERTIFICATE OF AUTHORITY RENEWAL FEE WILL RESULT IN SUMMARY SUSPENSION OF
THE ARIZONA CERTIFICATE OF AUTHORITY PURSUANT TO A.R.S. § 20-217(E).
Payment by check must be sent with this Report by March 31. If March 31 falls on a Saturday or Sunday, the deadline will be extended to the following
Monday for that year only. STATUTORY PENALTIES FOR LATE FILING AND/OR PAYMENTS WILL BE ENFORCED.
PLEASE NOTE OUR "POSTMARK POLICY" APPLICABLE TO STATUTORY FILINGS, AS IT IS ENFORCED BY THIS DEPARTMENT: To be
considered a TIMELY filing, the package containing the filing must display validation by the United States Postal Service* as proof of the date of filing.
Courier deliveries must include an invoice bearing the date of courier pick-up. If your package does not provide evidence of a timely filing it will be
considered filed WHEN RECEIVED and statutory penalties, where applicable, will be assessed. *Postage meter stamps do not qualify.
IMPORTANT: DUE TO CASH CONTROL PROCEDURES DO NOT MAIL THE ANNUAL FEES REPORT FORM OR PAYMENT INSIDE AN ANNUAL STATEMENT
FILING PACKAGE. SEPARATELY MAIL YOUR CHECK WITH THIS REPORT TO THE ATTENTION OF TAX UNIT AT ADDRESS SHOWN ABOVE.
E-LR (R
. 12/04)
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