Form E-Indins - Industrial Insured Premium Receipts Tax Report For The Period Of January 1 - July 20, 2011 Page 4
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5Complete Name of Insured
SECTION F: INSURANCE PROCURED FROM NON-ADMITTED INSURERS. Report each insurance policy
you procured directly (without the use of a surplus lines broker) from an unauthorized insurer.
For FULL PREMIUM AMOUNT, report the total gross premium, less premium returned on account of
cancellation or reduction of premium, charged for policies covering insurance for which some or all the
subjects of insurance are resident, located or to be performed in Arizona.
If the entirety of the property or risk covered by the policy was located in Arizona, enter 100% for "% of
property/risk w/in AZ"; otherwise, enter the percentage of premium that should be allocated to Arizona and
identify the criteria you applied to determine the percentage.
a. Policy Number
b. Coverage Start Date
c. Coverage Expiration
d. Date Premium Due/Paid
e. Full Name of Non-admitted Insurer or Lloyd's Broker/Syndicate
f. Insurer's or Lloyd's Broker Address
City
State
Country
ZIP Code
g. Type of Insurance
h. Property/Risk Covered by the Insurance
i.
j. % of property/risk w/in AZ
k. AZ PREMIUM AMOUNT
FULL PREMIUM AMOUNT
X
F1
%
=
$0.00
l. Which criteria did you use to allocate Arizona's portion of multistate premium (check all that apply):
100% AZ - not applicable
Physical assets
Employee payroll
Sales
Taxable income
Other (describe): __________________________________________________________________________
m. Total full-time employees or equivalents as of the date the policy was issued by the
unauthorized insurer:
n. If "F1k" was less than 80, the total full-time or equivalent employees of the insured's holding
company system as of the policy issuance date:
a. Policy Number
b. Coverage Start Date
c. Coverage Expiration
d. Date Premium Due/Paid
e. Full Name of Non-admitted Insurer or Lloyd's Broker/Syndicate
f. Insurer's or Lloyd's Broker Address
City
State
Country
ZIP Code
g. Type of Insurance
h. Property/Risk Covered by the Insurance
i.
j. % of property/risk w/in AZ
k. AZ PREMIUM AMOUNT
FULL PREMIUM AMOUNT
X
F2
=
%
$0.00
l. Which criteria did you use to allocate Arizona's portion of multistate premium (check all that apply):
100% AZ - not applicable
Physical assets
Employee payroll
Sales
Taxable income
Other (describe): __________________________________________________________________________
m. Total full-time employees or equivalents as of the date the policy was issued by the
unauthorized insurer:
n. If "F1k" was less than 80, the total full-time or equivalent employees of the insured's holding
company system as of the policy issuance date:
a. Policy Number
b. Coverage Start Date
c. Coverage Expiration
d. Date Premium Due/Paid
e. Full Name of Non-admitted Insurer or Lloyd's Broker/Syndicate
f. Insurer's or Lloyd's Broker Address
City
State
Country
ZIP Code
g. Type of Insurance
h. Property/Risk Covered by the Insurance
i.
j. % of property/risk w/in AZ
k. AZ PREMIUM AMOUNT
FULL PREMIUM AMOUNT
X
F3
=
%
$0.00
l. Which criteria did you use to allocate Arizona's portion of multistate premium (check all that apply):
100% AZ - not applicable
Physical assets
Employee payroll
Sales
Taxable income
Other (describe): __________________________________________________________________________
m. Total full-time employees or equivalents as of the date the policy was issued by the
unauthorized insurer:
n. If "F1k" was less than 80, the total full-time or equivalent employees of the insured's holding
company system as of the policy issuance date:
Industrial Insureds Premium Receipts Report
Page 4 of 5
Form E-IndIns (v20111027)
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