Form E-Sl-1 - Arizona Surplus Lines Broker Semi-Annual Statement And Premium Tax Report - 2004 Page 2

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JANUARY 1, 2004 THROUGH JUNE 30, 2004 SEMI-ANNUAL STATEMENT AND PREMIUM TAX REPORT
of Arizona Surplus Lines Broker ______________________________________Arizona License Number
(Type exact name as on license)
PART A - EXHIBIT OF SURPLUS LINES PREMIUMS
** Enter "0" or "None" Where Applicable - Do Not File a Blank Statement **
Line of Business
Aggregate Gross
Return Premiums
Aggregate
Fire Portion of
Description
Premiums Charged
Paid to Insureds
Net Premiums
Net Premiums
Disability (includes accident)
$
(-)$
= $
$
XXXXXXXXX
[DA Gross]
[DA Tax]
$
(-)$
= $
Property - Fire
$
[PF Gross]
[PF Tax]
$
(-)$
= $
Property - All Other
$
[PO Gross]
[PO Tax]
$
(-)$
= $
Marine & Inland Transportation
$
[MT Gross]
[MT Tax]
$
(-)$
= $
Vehicle - Aircraft
$
[VA Gross]
[VA Tax]
$
(-)$
= $
Vehicle - Land
$
[VL Gross]
[VL Tax]
$
(-)$
= $
Casualty
$
XXXXXXXXX
[C Gross]
[C Tax]
$
(-)$
= $
Surety
$
XXXXXXXXX
[S Gross]
[S Tax]
Purchasing Groups (Attach Form E-SL-1.RPG)
$
(-)$
= $
$
XXXXXXXXX
[PG Gross]
[PG Tax]
$
(-)$
= $
Other - Describe
$
[OT Gross]
[OT Tax]
$
(-)$
= $
TOTAL OF ALL COLUMNS
$
[SL Gross]
[SLF Gross/Tax]
LESS EXEMPT PREMIUMS (ATTACH LIST IDENTIFYING EACH INSURED,
(-)$
AMOUNTS AND BASIS OF EXEMPTION)
[SLX]
= $
TOTAL SURPLUS LINES PREMIUMS SUBJECT TO TAX
[SL Taxable]
Surplus Lines Tax Rate
3%
$
SURPLUS LINES PREMIUM TAX DUE (Total Premiums Subject to Tax times 0.03)
A
A
R
R
I
I
Z
Z
O
O
N
N
A
A
D
D
E
E
P
P
A
A
R
R
T
T
M
M
E
E
N
N
T
T
O
O
F
F
I
I
N
N
S
S
U
U
R
R
A
A
N
N
C
C
E
E
M
:
AKE CHECK PAYABLE TO
Attention: COMPLIANCE SECTION
:
MAIL CHECK WITH REPORT TO
2910 North 44
Street, Second Floor
th
Phoenix, Arizona 85018-7256
E-SL-1 (R
. 07/04)
P
2
2
EV
AGE
OF

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