Form Rrg-T - Annual Report Of Premiums,taxes,and Fees Of Registered Risk Retention Groups - 2011 Page 2

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ARKANSAS INSURANCE DEPARTMENT
2011 FORM AID AC RRG-T
ACCOUNTING DIVISION
ACCOUNTING DIVISION
1200 WEST THIRD STREET
DUE MARCH 1, 2012
LITTLE ROCK, AR 72201-1904
_______ ORIGINAL FILING
PHONE: (501) 371-2605
_____ AMENDED FILING
_____REFUND DUE
ANNUAL REPORT OF PREMIUMS, TAXES, AND FEES OF
REGISTERED RISK RETENTION GROUPS
STATE OF DOMICILE
NAIC COMPANY CODE (5 digit code)
COMPANY NAME
MAILING ADDRESS
CITY, STATE, ZIP CODE
CONTACT PERSON
TITLE
TELEPHONE NUMBER
EXT
FAX NUMBER
EMAIL ADDRESS
ARKANSAS TAX
A.
PREMIUM TAX COMPUTATION:
1. Total direct written premiums paid for risks
0.00
insured in Arkansas during calendar year 2011
$_____________________________________________
2. Finance and Service Charges, Policy Membership
0.00
and other Fees paid
$_____________________________________________
0.00
3. Net Taxable Premiums (Lines 1 + 2)
$_____________________________________________
0.00
4. Tax thereon at 4%
$_____________________________________________
Amount cannot be less than zero
B. FEES:
5. Certificate of Registration Renewal
$
200.00 __________________________
6. Filing Annual Statement
$
50.00
_______________________
7. Total Fees Due (Lines 5 + 6)
$
250.00
____________________
C. TOTAL TAXES AND FEES DUE:
250.00
8. Enter Total of Lines 4 + 7
$____________________________________________
Page 2 of 3
REVISED 2011

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