Form Fprf - Annual Report Of Premiums And Taxes For Property And Casualty Insures For The Fprf Premium Tax Fund - 2011 Page 2

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ARKANSAS INSURANCE DEPARTMENT 2011 FORM AID AC FPRF
ACCOUNTING DIVISION
ACCOUNTING DIVISION
1200 WEST THIRD STREET
DUE MARCH 1, 2012
LITTLE ROCK, AR 72201-1904
PHONE: (501) 371-2605
___ ORIGINAL FILING
___ AMENDED FILING
___REFUND DUE
ANNUAL REPORT OF PREMIUMS & TAXES
FOR PROPERTY & CASUALTY INSURERS
FOR THE FPRF PREMIUM TAX FUND
STATE OF DOMICILE
NAIC COMPANY CODE
(5 digit code)
COMPANY NAME
MAILING ADDRESS
CONTACT PERSON
TITLE
TELEPHONE NUMBER
EXT
FAX NUMBER
EMAIL ADDRESS
100% of premiums written for Arkansas coverages on real and personal property are to be reported for Lines 1
(fire), 2.1 (allied lines), 2.2 (multiple peril crop), 3 (farm owners multiple peril), 4 (homeowners multiple peril), 5.1
(commercial multiple peril (non-liability)), 8 (ocean marine), 9 (inland marine), 12 (earthquake), 21.1 (private
passenger auto physical damage), 21.2 (commercial auto physical damage), 22 (aircraft-all perils), 26 (burglary
and theft), 27 (boiler and machinery), 30 (warranty) and 34 (aggregate write in for other lines of business) of the
2010 Arkansas State Page.
ARKANSAS TAX
1. Direct Written Premiums, from page 2, including finance and
0.00
service charges, and other fees and all other considerations for insurance.
$____________________
0.00
2. Less Dividends paid/credited to Policyholders on direct business.
$(___________________)
0.00
3. Net Taxable Premiums
$____________________
0.00
4. Tax Thereon at 1/2 of 1 % *FIGURE CANNOT BE LESS THAN ZERO
$____________________
0.00
5. Less Quarterly Prepayments from below
$(___________________)
0.00
6. Net Payment For Calendar Year 2011
$____________________
MAKE CHECK PAYABLE TO: FPRF PREMIUM TAX FUND
2011 Quarterly FPRF-Q Prepayments
First quarter
check #
$
0
0.00
Second quarter
check #
$
0
0.00
Third quarter
check #
$
0
0.00
Page 1 of 2
REVISED 2011

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