Form E-Title.foreign - Annual Fees Report Foreign Title Insurer - Az Department Of Insurance - 2002

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ARIZONA DEPARTMENT OF INSURANCE
2002 ANNUAL FEES REPORT
DUE DATE: MARCH 1, 2003
FOREIGN TITLE INSURER
PREMIUM TAX UNIT
(602) 912-8429
FAX (602) 912-8421
For Office Use Only
For Audit Use Only
ORIGINAL REPORT
AMENDED REPORT / REASON __________________________ ______________________________________________________
Complete Company Name and Home Office Address
State of Incorporation
x
x
x
NAIC Number
x
NAIC Group Number
x
Federal I. D. Number
x
Preparer’s Name and Title:
E-Mail Address:
Toll Free or Collect Phone: (
)
FAX: (
)
Complete Mail Address:
Enter Total Direct Arizona Premiums Written this calendar year period
$
(TI GROSS/TAX)
SUMMARY OF ANNUAL FEES DUE MARCH 1, 2003
1)
Certificate of Authority Renewal Fee
$
135.00
(Pay Code 58)
2)
Annual Statement Filing Fee
$
300.00
(Pay Code 28)
3)
TOTAL DUE MARCH 1, 2003 – (DO NOT ROUND TO NEAREST DOLLAR)
$
435.00
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AKE CHECK PAYABLE TO
Attention: TAX UNIT
A
:
2910 North 44
Street, Second Floor
ND MAIL CHECK WITH REPORT TO
th
Phoenix, ARIZONA 85018-7256
PREPARER CERTIFICATION
COMPANY OFFICER CERTIFICATION
I certify that I have prepared this report. It is true, complete and correct to the best of
I certify that I have examined this report. It is true, complete and correct to the best of
my knowledge.
my knowledge.
SIGNATURE OF PREPARER
DATE
SIGNATURE OF OFFICER
DATE
NAME AND TITLE TYPED OR PRINTED
NAME AND TITLE TYPED OR PRINTED
E-TITLE.F
(R
12/02)
P
1
1
OREIGN
EV
AGE
OF

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