Form E-Sl-2 - Semi-Annual Statement And Premium Tax Report - 2001 Page 2

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JULY 1, 2001 THROUGH DECEMBER 31, 2001 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]
$
(-)$
= $
$
XXXXXXXXX
Casualty
[C Gross]
[C Tax]
$
(-)$
= $
$
XXXXXXXXX
Surety
[S Gross]
[S Tax]
Purchasing Groups (Attach Form E-SL-2.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)
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AKE CHECK PAYABLE TO AND
Attention: TAX UNIT
2910 North 44
Street, Second Floor
th
:
MAIL CHECK WITH REPORT TO
Phoenix, Arizona 85018-7256
E-SL-2 (R
. 12/01)
P
2
2
EV
AGE
OF

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