Form E-Healthorg - Health Organization Annual Tax And Fees Report
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5HEALTH ORGANIZATION
DEPARTMENT OF INSURANCE
STATE OF ARIZONA
ANNUAL TAX AND FEES REPORT
Financial Affairs Division – Tax Unit
DUE MARCH 1
th
2910 North 44
Street, Suite 210
Phoenix, Arizona 85018-7269
Phone: (602) 364-3998
ENTER CALENDAR YEAR ________
Fax: (602) 364-3989
Reset
This tax report form must be filed by the following types of insurers ONLY:
HOSPITAL, MEDICAL, DENTAL AND
HEALTH CARE SERVICES
PREPAID DENTAL PLAN
OPTOMETRIC SERVICE
ORGANIZATION
ORGANIZATION
CORPORATION
ORIGINAL REPORT
AMENDED REPORT / REASON:
Complete Company Name and Mail Office Address
State of Incorporation (Domicile)
X
X
X
NAIC Number:
X
Federal I. D. Number:
X
Phone:
Preparer’s Name and Title:
Preparer’s Mail Address:
Preparer’s Toll Free/Collect Phone:
E-Mail Address:
FAX:
Enter your initials and the date to certify that this report is
true, complete and correct to the best of your knowledge
Initials
Date
Click a YES or NO response to each question below before proceeding to Page 2
Responses may label certain pages of this report as “NOT REQUIRED”
YES
NO
Are you an approved Accountable Health Plan in Arizona?
Are you a Hospital, Medical, Dental or Optometric Service Corporation?
Did you make contributions to a School Tuition Organization in Arizona?
You can no longer pay taxes and fees by ACH credit. You can electronically pay taxes and fees via
the NAIC OPTins system.
To pay by check make your check payable to Arizona Department of Insurance and mail it with this form.
If you are filing a hard copy, attach copies of Schedule T and Arizona State Page 29.
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-HEALTHORG (R
. 11/09)
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EV
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Parent category: Financial