Form E-Annualtax - Annual Premium Tax And Fees Report - Arizona Department Of Insurance - 2002 Page 2
ADVERTISEMENT
1
2
3Company Name:
NAIC # ______________
PART A – 2002 ARIZONA PREMIUM TAX COMPUTATION
Total Arizona Premiums includes policy membership, other fees and all other considerations for insurance from all classes of insurance whether designated as a premium or otherwise received on accounts of policies and
contracts after deducting applicable cancellations, returned premiums, policy dividends, refunds, savings coupons and other similar returns paid or credited to policyholders and not reapplied as premiums for new, additional or
extended insurance.
IMPORTANT! Attach copies of Schedule T and Arizona Business Page from 2002 Annual Statement
Life/Disability Insurers
Column 1
Property/Casualty; Mortgage Guaranty; Prepaid Legal; Risk Retention Group
Column 2
1.
1.
Arizona Life Premiums from Schedule T line 3, Column 2
Arizona Workers’ Compensation Premiums (AZ State Page 24, line 16, Column 1)
(WC Gross)
$
$
(LI Gross)
Less Deductions:
Less Deductions:
a) Paid in cash or left on deposit
(-) $
a) (Specify)
(-) $
2.
b) Applied to pay renewal premiums (Only if included in line 1)
Taxable Workers’ Compensation Premiums (line 1 minus 1a)
(WC TAX)
(-) $
$
3.
c) Other (Describe and document)
Tax Rate
3%
(-) $
2.
Taxable Life Premiums (line 1 minus 1a, 1b, and 1c)
4.
Workers’ Compensation Tax Due (line 2 x line 3)
(LI Tax)
$
3.
Tax Rate
5.
Arizona Fire Tax Due from Form Sch-AFP (Line G, sum of Columns 1 & 3)
(FT)
2%
$
4.
6.
Life Tax Due (line 2 x line 3)
Arizona Accident & Health Premiums (
AZ State Page 24, lines 13 through 15.7, Col. 1)
(AH Gross)
$
$
(LT)
Arizona Annuity Considerations from Schedule T, line 3, Column
5.
a) Less: Dividends Paid or Credited on Direct Business
(-)
(AN Gross)
3
$
$
Arizona Accident & Health Premiums (Life, A&H Sch T, line 3,
6.
b) Less: Exempt Accountable Health Plan Small Group
(-)
(AH Gross)
(SG)
Column 4 or Health Sch T, line 3, sum of Columns 3, 4, 5 & 6)
$
$
a) Less: Dividends Paid or Credited on Direct Business
(-) $
c) Less: Other Deductions (Describe and document)
(-) $
b) Less: Exempt Accountable Health Plan Small Group (See Note
(-)
7.
Taxable Accident & Health Premiums (line 6 minus 6a, 6b and 6c)
(AH Tax)
(SG)
1 Below)
$
$
c) Less: Other Deductions (Describe and document)
(-) $
8.
Tax Rate
2%
7.
9.
Taxable Accident & Health Premiums (line 6 minus 6a, 6b, and 6c)
Accident & Health Tax Due (line 7 x line 8)
(AH Tax)
(AHT)
$
$
8.
10.
Tax Rate
All Other Property & Casualty Premiums (See Note Below)
(PC Gross)
2%
$
9.
Accident & Health Tax Due (line 7 x line 8)
(AHT)
$
NOTE: Annual Statement Arizona State Page 24, column 1, line 34 plus Finance and Service
Charges, minus line 1 above, minus line 6 above, and minus any premiums segregated and
10.
Add lines 4, and 9 (Carry Amount to Sch-RT, Column C, line 9)
$
subject to Fire Tax ONLY on Form Sch-AFP.
Less deductions, excluding amounts already
(GT)
deducted from Workers’ Compensation, Fire, and Accident and Health Premiums.
ALL FOREIGN AND ALIEN INSURERS MUST COMPLETE RETALIATORY FORM SCH-RT
a) Less: FCIC Reinsured Crop Hail (Attach Affidavit)
(-) $
(FC)
A.R.S.§ 20-2301 et seq ACCOUNTABLE HEALTH PLAN ACTIVITY IN CALENDAR YEAR 2002
b) Less: Other Deductions (Describe and document)
(-) $
Complete if claiming Exempt Accountable Health Plan Small Group Premiums in either Column 1, line 6b or
11.
Taxable Property & Casualty Premiums (line 10 minus 10a and 10b)
(PC TAX)
Column 2, line 6b on this page.
$
1. Number of Health Benefit Plans issued to small employers with 2, but not
12.
Tax Rate
(50P)
2%
#
more than 50 eligible employees
2. Number of lives covered by the Health Benefits Plan on line 1
13.
Property & Casualty Tax Due (line 11 x line 12)
(50L)
(PCT)
#
$
N
1: T
amount reported in Line 6B, Column 1 or Column 2 must be supported with a
OTE
HE
14.
Additional Vehicle Tax Due from Form Sch-AVP, line G
$
complete list of the names of the small employers and the amount of premiums paid by each.
15.
Add lines 4, 5, 9, 13, and 14 (Carry Amount to Sch-RT, Column C, line 9)
N
2: Exempt Federal Employee Health Benefit Plan premiums must be reported in Line 6,
OTE
$
Column 1 or Column 2 and deducted in Line 6c of Column 1 or Column 2, respectively.
ALL FOREIGN AND ALIEN INSURERS & RISK RETENTION GROUPS MUST COMPLETE RETALIATORY FORM SCH-RT
E-ANNUALTAX (12/02)
PAGE 2 OF 3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Uc-018 - Unemployment Tax And Wage Report - Arizona Department Of Economic Security - 2004
Financial
Related Categories
Parent category: Financial