Form E-Rg - Foreign Risk Retention Group Annual Tax Report Page 2
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7COMPANY NAME:
State Of Incorporation:
NAIC#:
YEAR:
ARIZONA PREMIUM TAX
Include Finance & Service Charges
Arizona Premiums
PC
1
Gross premiums
Gross
2
Dividends
3
Other deductions – Describe:
UP
PC
0.00
4
Taxable premiums
Tax
Tax rate
2%
0.00
5
Tax
PCT
0.00
6
Additional Vehicle Tax (Page 3)
Goto Page 3
05
0.00
7
Gross Tax
GT
Credits and Offsets:
0.00
8a.
STO Credits (Page 4)
Goto Page 4
ST1
0.00
8b.
STO Credits for Displaced Students or Students With Disabilities (Page 4)
ST2
TAO/
0.00
9
Total Credits and Offsets
TC
0.00
10
Net Tax
IB
↑ Installment
↑
Tax Base
0.00
11
ENTER INSTALLMENT TAXES PAID BELOW (Exclude penalty & interest)
TOTAL=
TIP
11a
March 15
11d
June 15
11b
April 15
11e
July 15
11c
May 15
11f
August 15
0.00
12 a
NT / 07
Premium Tax Due
0.00
12 b
Overpayment to be refunded
SR
0.00
Retaliatory Amount Due (Page 7)
Goto Page 7
13
04
0.00
14
Total taxes due
You can no longer pay taxes and fees by ACH credit. You can electronically pay taxes and fees via the
NAIC OPTins system. For information about OPTins:
•
Visit the NAIC Web site at
•
Contact the OPTins Help Desk at
or (816) 783-8990
Note: To use OPTins, you must establish an account and electronic funds transfer protocol with the NAIC,
which can take up to two weeks
To pay by check make your check payable to Arizona Department of Insurance and mail it with this form.
IMPORTANT: Do not mail this form or your payment inside your Annual Statement package. Mail your
check with this report separately to Attention: Tax Unit at the address above.
We may assess a civil penalty and interest if you pay tax late. ARS § 20-225(A).
E-RG (11/09)
Arizona Department of Insurance
Page 2 of 7
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