Form E-Sl-Final - Az Surplus Lines Broker Final Statement And Premium Tax Report - 2004 Page 2

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ARIZONA SURPLUS LINES BROKER FINAL STATEMENT AND PREMIUM TAX REPORT
FOR REPORTING PERIOD OF:
THROUGH
DATE OF SURPLUS LINES BROKER LICENSE TERMINATION:
of Arizona Surplus Lines Broker ________________________________________ Arizona License Number
(Type exact name as on license)
PART A - EXHIBIT OF SURPLUS LINES PREMIUMS
** Enter "0" or "None" Where Applicable - Do Not File a Blank Statement **
Line of Business
Aggregate Gross
Return Premiums
Aggregate
Fire Portion of
Description
Premiums Charged
Paid to Insureds
Net Premiums
Net Premiums
Disability (includes accident)
$
(-)$
= $
0.00
$
XXXXXXXXX
[DA Gross]
[DA Tax]
Property - Fire
$
(-)$
= $
$
[PF Gross]
[PF Tax]
Property - All Other
$
(-)$
= $
$
[PO Gross]
[PO Tax]
Marine & Inland Transportation $
(-)$
= $
$
[MT Gross]
[MT Tax]
Vehicle - Aircraft
$
(-)$
= $
$
[VA Gross]
[VA Tax]
Vehicle - Land
$
(-)$
= $
$
[VL Gross]
[VL Tax]
Casualty
$
(-)$
= $
$
XXXXXXXXX
[C Gross]
[C Tax]
Surety
$
(-)$
= $
$
XXXXXXXXX
[S Gross]
[S Tax]
Purchasing Groups
Attach Form E-SL-1.RPG
$
(-)$
= $
$
XXXXXXXXX
[PG Gross]
[PG Tax]
Other - Describe
$
(-)$
= $
$
[OT Gross]
[OT Tax]
0.00
0.00
0.00
TOTAL OF ALL COLUMNS
$
(-)$
= $
$
[SL Gross]
[SLF Gross/Tax]
0.00
TOTAL SURPLUS LINES PREMIUMS SUBJECT TO TAX
= $
[SL Taxable]
3%
Surplus Lines Tax Rate
$
0.00
SURPLUS LINES PREMIUM TAX DUE (Total Premiums Subject to Tax times 0.03)
PAYMENT OPTIONS – CHECK ONLY ONE
:
OPTION FOR REMITTANCE OF THE AMOUNT DUE ABOVE
(
)
-
.
ACH DELIVERY
OPTION AVAILABLE TO FIRMS ONLY
USE FORMAT AND CONTENT PRESCRIBED IN FORM E
ACH
INSTRUCTION
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C
E IS ENCLOSED WITH THIS REPORT
A
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CHECK PAYABLE TO
MAIL THIS REPORT TO:
Attention: COMPLIANCE SECTION
ARIZONA DEPARTMENT OF INSURANCE
2910 North 44
Street, Suite 210
th
Phoenix, Arizona 85018-7256
E-SL-FINAL (R
. 12/04)
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EV
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