Form E-Indins - Industrial Insured Premium Receipts Tax Report For The Period Of January 1 - July 20, 2011 Page 3

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Complete Name of Insured
SECTION E: ALLOCATING PREMIUM TAXES FOR INSURANCE COVERING MULTISTATE RISKS.
E1.
Between January 1 and June 20, 2011, did you procure any insurance from one or more unauthorized
insurer that covered property or risks that were only partly within Arizona?
Yes (the insured procured insurance from unauthorized insurers covering multistate risks)
No (insurance procured from unauthorized insurers only covered risks entirely within Arizona)
If you answered "No," leave the remainder of SECTION E blank and proceed to SECTION F.
Otherwise, complete the remainder of SECTION E.
If you answered "Yes" to E1, ARS § 20-401.07 and Arizona Administrative Code R20-6-206(D) require
you to report the information in E2 through E5, below:
E2.
Percentage of physical assets in Arizona:
[a].
Physical assets located in Arizona:
_______________
[b].
Total physical assets
:
_______________
[c].
Percentage of total physical assets located in Arizona ([a] / [b]):
_______________
E3.
Percentage of employee payroll in Arizona:
[a].
Arizona employee payroll:
_______________
[b].
Total employee payroll:
_______________
[c].
Percentage of total employee payroll in Arizona ([a] / [b]):
_______________
E4.
Percentage of sales in Arizona:
[a].
Arizona sales:
_______________
[b].
Total sales:
_______________
[c].
Percentage of total sales in Arizona ([a] / [b]):
_______________
E5.
Percentage of taxable income reportable in Arizona:
[a].
Arizona-reportable taxable income:
_______________
[b].
Total taxable income:
_______________
[c].
Percentage of taxable income reportable in Arizona ([a] / [b]):
_______________
Form E-IndIns (v20111027)

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