Form E-Annualtax - Annual Premium Tax And Fees Report - Arizona Department Of Insurance - 2002
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3ARIZONA DEPARTMENT OF INSURANCE
PREMIUM TAX UNIT
(602) 912-8429
FAX (602) 912-8421
DUE DATES: FOREIGN AND ALIEN:
MARCH 1, 2003
2002 ANNUAL PREMIUM TAX AND FEES REPORT
ARIZONA DOMESTIC:
MARCH 1, 2003
THIS FORM SHOULD BE USED FOR ALL OF THE FOLLOWING DOMESTIC, FOREIGN AND ALIEN INSURERS:
LIFE & DISABILITY
PROPERTY & CASUALTY
MORTGAGE GUARANTY
PREPAID LEGAL
RISK RETENTION
INSURER
INSURER
INSURER
INSURER
GROUP
For Office Use Only
For Audit Use Only
NOTE:
Insurers filing the Health Annual Statement
must use this form. See Page 2, Column 1,
line 6.
ORIGINAL REPORT
AMENDED REPORT
Complete Company Name and Home Office Address
State of Incorporation
X
X
X
NAIC Number
X
NAIC Group Number
X
Federal I. D. Number
Preparer’s Name and Title:
E-Mail Address:
Toll Free or Collect Phone: (
)
FAX: (
)
Complete Mail Address:
PART C – SUMMARY OF TAXES AND FEES DUE
1)
Retaliatory Amount (Sch-RT, Page 1, column B, line 36 , not less than zero)
$
(Pay Code 04)
2)
Premium Tax (Part B, Page 3, Column 1, Line 8a or Column 2, Line 10a, not less than zero)
$
3)
Certificate of Authority Renewal Fee: (a) Domestic Life & Disability Insurer Only
$1,500.00
$
(a)
ENTER
(Pay Code 56)
ENTER ONLY
(b) ALL OTHER INSURERS
$135.00
(b)
$
ENTER
(Pay Code 58)
ONE FEE
(c) No Fee for Risk Retention Groups
$0
$
(c)
ENTER
N/A
4)
Annual Statement Filing Fee
$
300.00
(Pay Code 28)
5)
TOTAL DUE March 1, 2003
$
(Add lines 1 through 4, above – DO NOT ROUND TO NEAREST DOLLAR)
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AKE CHECK PAYABLE TO
:
Attention: TAX UNIT
AND MAIL CHECK WITH REPORT TO
2910 North 44
Street, Second Floor
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
I certify that I have examined this report. It is true, complete and correct to the best
best of my knowledge.
of my knowledge.
SIGNATURE OF PREPARER
DATE
SIGNATURE OF OFFICER
DATE
NAME AND TITLE TYPED OR PRINTED
NAME AND TITLE TYPED OR PRINTED
E-ANNUALTAX (12/02)
PAGE 1 OF 3
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