Form E-Survey.other - Survey Of Other Arizona Insurers - 2000 Calendar Year Reporting Period

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Arizona Department of Insurance
Financial Affairs Division
2910 North 44th Street, Second Floor
Phoenix, Arizona 85018-7256
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Phone: (602) 912-8429 Fax: (602) 912-8421
SURVEY OF OTHER ARIZONA INSURERS - 2000 CALENDAR YEAR REPORTING PERIOD
COMPANY NAME
NAIC NUMBER:_________________________________
This survey is required to be filed with the Annual Premium Tax and Fees Report, pursuant to A.A.C. R20-6-206.
OTHER INSURANCE BUSINESS
Schedule T
Finance and Service
Taxed Premiums &
Local & Regional
STATE
Premiums
Charges
Considerations
Taxes Paid
(Per State Tax Reports)
(Counties, Cities, etc.)
[Do Not Add Columns 1and 2]
(1)
(2)
(3)
(4)
Alabama
$
$
$
$
Georgia
$
$
$
$
Kentucky
$
$
$
$
Louisiana
$
$
$
$
Missouri
$
$
$
$
New York
$
$
$
$
South Carolina
$
$
$
$
West Virginia
$
$
$
$
I certify that the information contained in this survey has been truthfully and accurately reported.
Preparer's Name and Title
Date
Signature
Phone Number
Form E-SURVEY.OTHER (Rev. 12/00)
Page 1 of 1

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