Form E-Rg - Foreign Risk Retention Group Annual Tax Report Page 7
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7COMPANY NAME:
State Of Incorporation:
NAIC#:
YEAR:
RETALIATORY TAXES AND FEES WORKSHEET
You must complete this page
In the State of Incorporation column, enter the amounts that a like Arizona insurer was required to pay to
your state of incorporation, using your Arizona business as the base amount for fees, assessments and
taxes imposed for this calendar year. In the Arizona column, enter only amounts you actually paid in the
year specified above. Call (602) 364-3997 if you need assistance with this worksheet.
Part 1: TAXES A
TTACH SUPPORTING DOCUMENTATION FOR ALL DEDUCTION AMOUNTS REPORTED
GROSS
(A)
(B)
(C)
PREMIUMS
TYPE OF
TAX
TAXABLE
ARIZONA
DEDUCTIONS
(Including Finance
STATE OF
INSURANCE
RATE
PREMIUM
& Service
INCORPORATION
Charges)
xxxxxxxxxxxxxxx
0.00
% $
0.00
1
Property & Casualty
$
$ (
) $
xxxxxxxxxxxxxxx
2
0.00
0.00
% $
Fire Marshal Tax
$
$ (
) $
0.00
0.00
xxxxxxxxxxxxxxx
3
% $
Other:
$
$ (
) $
0.00
0.00
4
xxxxxxxxxxxxxxx
% $
Other:
$
$ (
) $
(Column C=Page 2, line 7)
5 Subtotal # 1
0.00
0.00
0.00
$
XXXXXX $
$
Part 2: FEES A
/
TTACH COPIES OF PAYMENTS AND
OR SUPPORTING SCHEDULES FOR EACH ITEM REPORTED
xxxxxxxxxxxxxxx
Certificate of Authority renewal fee
6
$
xxxxxxxxxxxxxxx
Annual Statement filing fee
7
$
xxxxxxxxxxxxxxx
Publication fees
8
$
xxxxxxxxxxxxxxx
Policies, rates and forms filing fees
9
$
Goto Page 5
0.00
xxxxxxxxxxxxxxx
Agent Appointment fees from Page 5, line C
10
$
0.00
xxxxxxxxxxxxxxx
Agent Termination fees from Page 5, line F
11
$
xxxxxxxxxxxxxxx
Other fees (filing articles, bylaws, amendments) – Describe:
12
$
0.00
0.00
13
$
$
Subtotal # 2
PART 3: ASSESSMENTS A
TTACH COPIES OF PAYMENTS AND
/
OR SUPPORTING SCHEDULES FOR EACH ITEM
Fraud Fund
14
$
$
Fraudulent Claims
California insurers - enter # of AZ vehicles
#
xxxxxxxxxxxxxxx
15
$
xxxxxxxxxxxxxxx
Other State of Incorporation Assessments – Describe:
16
$
0.00
0.00
17
$
$
Subtotal # 3
PART 4: OTHER TAXES A
/
TTACH COPIES OF PAYMENTS AND
OR SUPPORTING SCHEDULES FOR EACH ITEM
xxxxxxxxxxxxxxx
State income tax paid/payable for this tax year
18
$
[ A
P
-F
R
]
TTACH
RO
ORMA
ETURN
xxxxxxxxxxxxxxx
State income tax credit against premium tax for this tax year
19
$ (
)
xxxxxxxxxxxxxxx
State franchise tax paid/payable for this tax year [ A
20
$
P
-F
R
]
TTACH
RO
ORMA
ETURN
xxxxxxxxxxxxxxx
State franchise tax credit against premium tax for this tax year
21
$ (
)
Goto Page 6
xxxxxxxxxxxxxxx
0.00
Local/Regional Tax - from Page 6
22
xxxxxxxxxxxxxxx
Fire Marshal/Fire District taxes (not reported above in Part 1)
23
$
xxxxxxxxxxxxxxx
Other State of Incorporation taxes - Describe:
24
$
0.00
$0.00
25
$
Subtotal # 4
0.00
Retaliatory Worksheet Totals – Sum of Subtotals 1, 2, 3, and 4
0.00
(DOM)
26
$
$
0.00
Total of Arizona column C, line 26
27
$
(RT)
Not less than 0.
28
Retaliatory Amount Due
0.00
$
E-RG (11/09)
Arizona Department of Insurance
Page 7 of 7
Goto Page 2
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