Form E-Ucldr - Unaffiliated Credit Life & Disability Reinsurer Annual Fees Report
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DEPARTMENT OF INSURANCE
UNAFFILIATED CREDIT LIFE &
STATE OF ARIZONA
DISABILITY REINSURER
Financial Affairs Division- Tax Unit
ANNUAL FEES REPORT
th
2910 North 44
Street, Suite 210
Phoenix, Arizona 85018-7269
FOR CALENDAR YEAR _______
Phone: (602) 364-3997
Fax: (602) 364-3989
YOU MUST FILE THIS REPORT AND PAY FEES BY:
AUGUST 1* IF YOUR FISCAL YEAR ENDS 12/31
OR
NOVEMBER 1* IF YOUR FISCAL YEAR END IS NOT 12/31
Do not file this form if you pay your fees via the NAIC OPTins system or if you pay your
fees with the notice we mailed to you.
State of Incorporation
Complete Company Name and Mail Address
X
ARIZONA
dddd
X
Arizona Company Number:
X
Federal I. D. Number:
X
Phone:
Preparer’s Name and Title:
Preparer’s Mail Address:
Preparer’s Toll Free/Collect Phone:
E-Mail Address:
FAX:
Annual Fees Due:
1)
Certificate of Authority Renewal Fee
$
4,500.00
(Pay Code 57)
2)
Annual Statement Filing Fee
$
300.00
(Pay Code 28)
3)
$
4,800.00
TOTAL ANNUAL FEES DUE
You can no longer pay fees by ACH credit.
You can electronically pay fees using the NAIC
OPTins system.
To pay by check make your check payable to Arizona Department of Insurance and mail it with
this form to the address above.
IMPORTANT: DO NOT MAIL THIS FORM OR YOUR PAYMENT INSIDE YOUR ANNUAL
STATEMENT PACKAGE. MAIL YOUR CHECK WITH THIS REPORT SEPARATELY, ATTENTION
TAX UNIT TO THE ADDRESS ABOVE.
We may summarily suspend your Arizona Certificate of Authority if you do not pay your
Certificate of Authority Renewal Fee by the due date. ARS § 20-217(E).
We may assess a penalty fee of up to $25 per day if you pay fees late. ARS § 20-223(D).
E-UCLDR (R
. 7/09)
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