2011 Form Aid Ac Ci-T - Annual Report Of Premiums, Taxes, And Fees Of All Captive Insurance Companies - Arkansas Insurance Department Page 3

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ARKANSAS INSURANCE DEPARTMENT
2011 FORM AID AC CI-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 ALL
CAPTIVE INSURANCE COMPANIES
NAIC COMPANY CODE (5 digit code)
COMPANY NAME
MAILING ADDRESS
CONTACT PERSON
TITLE
TELEPHONE NUMBER
EXT
FAX NUMBER
EMAIL ADDRESS
A.
COMPUTATION OF PREMIUM TAX:
0.00
1. Total Direct Premiums as described in ACA 23-63-1614(a)
$___________________
0.00
a. .4% of $1.00 - $20,000,000.00
$___________________
0.00
b. .3% of $20,000,001.00 - $40,000,000.00
$___________________
0.00
c. .2% of $40,000,001.00 - $60,000,000.00
$___________________
0.00
d. .075% of each dollar thereafter
$___________________
0.00
e. Net premium tax due (a thru d)
$___________________
0.00
2. Reinsurance Written
$___________________
0.00
a. .225% of $1.00 - $20,000,000.00
$___________________
0.00
b. .150% of $20,000,001.00 - $40,000,000.00
$___________________
0.00
c. .050% of $40,000,001.00 - $60,000,000.00
$___________________
0.00
d. .025% of each dollar thereafter
$___________________
0.00
e. Net premium tax due (a thru d)
$___________________
0.00
3. SUBTOTAL 1(E) + 2(E)
$________________***
***The minimum tax due is $5,000.00. This does NOT apply to insurers exempt from
premium tax under ACA 23-63-1614(I). Go to Section D
Page 1 of 3
Revised 2011

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