Statement Of Taxes And Fees Registered Self-Funded Health Care Plans - Idaho Department Of Insurance

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STATE OF IDAHO
DEPARTMENT OF INSURANCE
0560
700 WEST STATE STREET, 3rd FLOOR
FOR DEPARTMENT USE ONLY
1025
PO BOX 83720
1315-10
BOISE, ID 83720-0043
TOTAL
STATEMENT OF TAXES AND FEES
REGISTERED SELF-FUNDED HEALTH CARE PLANS
PLAN/TRUST NAME
REGISTRATION NO.
REPORTING ENTITY NAME
YEAR END DATE OF PLAN
REPORTING ENTITY MAILING ADDRESS
RECAP OF TAXES AND FEES
NUMBER OF BENEFICIARIES COVERED PER MONTH:
Year
Month
Beneficiaries
Year
Month
Beneficiaries
January
July
February
August
March
September
April
October
May
November
June
December
Total
Beneficiars:
$
1. TOTAL TAXES = TOTAL BENEFICIARIES_____________________ X .04
___________________________
500.00
$
2. ANNUAL CONTINUATION FEE IDAPA 18.01.44.03.a.viii. IDAHO CODE 41 - 4011(3)
________
___________
Payment of fee must be included
.
$______________________
Idaho Department of Insurance
3. BALANCE DUE – Make check payable to:
There will be a $20.00 charge on all returned checks. Idaho Code § 28-22-105
Your canceled check is your receipt.
Under penalty of perjury, I declare that this statement (including any accompanying schedules and statements) has been examined by
me and to the best of my knowledge and belief is a true, correct, and complete return.
Date
Signature
(
)
Telephone Number
Ext.
Name (Type or Print)
E-Mail Address
Title
INS-PTX-TRSF (10-11)

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