Form E-Indins.p - Industrial Insured Certified Statement Of Risk Percentage Allocations 2000

ARIZONA DEPARTMENT OF INSURANCE

Financial Affairs Division

Premium Tax Unit

2910 NORTH 44TH STREET, SECOND FLOOR

Phoenix, Arizona 85018-7256

Phone: (602) 912-8429

Fax:

(602) 912-8421

INDUSTRIAL INSURED CERTIFIED STATEMENT OF

RISK PERCENTAGE ALLOCATIONS

FOR CALENDAR YEAR 2000

Name of Industrial Insured:

___________________________________________________________________ _______________________________________

In accordance with the provisions of Arizona Revised Statutes § 20-401.07 and in compliance with Arizona Administrative Code R20-6-207(H), if an Industrial Insured

claims that its contract with an unauthorized insurer covers risks or exposures only partly in this state, the Industrial Insured shall file, in addition to and accompanying its

Premium Receipts Tax Return, a certified statement clearly disclosing information necessary for a determination of the criteria of percentage allocation of A.R.S. § 20-

401.07, including but not limited to:

a.

Percentage of physical assets in Arizona – Apportionment Code (PA).

Total Assets

Arizona Assets

Allocation Percentage

b.

Percentage of employee payroll in Arizona – Apportionment Code (EP).

Total Employee Payroll

Arizona Employee Payroll

Allocation Percentage

c.

Percentage of sales in Arizona – Apportionment Code (S).

Total Sales

Arizona Sales

Allocation Percentage

d.

Percentage of taxable income in Arizona – Apportionment Code (TI).

Total Taxable Income

Arizona Taxable Income

Allocation Percentage

This certification must be signed by same officer of the insured, or other person authorized to act for the insured who has executed the Premium

Receipts Tax Return Form E-INDINS.R.

I do hereby certify to the Arizona Director of Insurance that the above allocation percentages are true and correct to the best of my knowledge and belief.

(Type Name)

(Title)

(Signature)

(Date)

Signed and sworn to before me this

day of

, Year______

My commission expires:

NOTARY PUBLIC

ATTACH THIS FORM TO THE PREMIUM RECEIPTS TAX RETURN FORM E-INDINS.R

E-INDINS.P (Rev. 12/00)

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