Form E-Annualtax - Annual Premium Tax And Fees Report - Arizona Department Of Insurance - 2002 Page 3
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3Company Name:
NAIC #
PART B - ARIZONA PREMIUM TAXES DUE FOR CALENDAR YEAR 2002
Life/Disability Insurers
Column 1
Property/Casualty; Mortgage Guaranty; Prepaid Legal; Risk Retention Group
Column 2
1.
Life Tax from Part A, Page 2, Column 1, line 4
1.
Arizona Fire Tax from Part A, Page 2, Column 2, line 5
(Code 09)
$
$
2.
2.
Accident & Health Tax from Part A, Page 2, Column 1, line 9
Accident & Health Tax from Part A, Page 2, Column 2, line 9
(Code 07)
$
$
3.
3.
Gross Arizona premium taxes (add lines 1 and 2, above)
Property & Casualty Tax from Part A, Page 2, Column 2, line 13
(Code 07)
$
$
4.
4.
Less Allowable Credits and Offsets:
Additional Vehicle Tax from Part A, Page 2, Column 2, line 14
(Code 05)
$
5.
a) Total Available Guaranty Fund Offsets - Form Sch-APTO
Gross Arizona premium taxes (add lines 1 through 4, above)
(TGF)
(GT)
$
$
b) Enterprise Zone Credits
6.
Less Allowable Credits and Offsets:
[ A
F
E-Z
]
TTACH
ORM
ONE
$
(EZC)
c) Military Reuse Zone Credits
a) Total Available Guaranty Fund Offsets - Form Sch-APTO
[ A
F
M-Z
]
(TGF)
TTACH
ORM
ONE
$
$
(MZC)
d) Domestic Insurers ONLY-$567.50 per A.R.S. § 20-167(D)
b) Enterprise Zone Credits
(SC)
[ A
F
E-Z
]
(EZC)
$
TTACH
ORM
ONE
$
e) Total Credits and Offsets (add lines 4a through 4d)
c) Military Reuse Zone Credits
[ A
F
M-Z
]
(TAO)
(MZC)
TTACH
ORM
ONE
$
$
5.
Enter the LESSER amount of line 3 or line 4e
d) Total Credits and Offsets (add lines 6a through 6c)
(TC)
(TAO)
$
$
7.
Enter the LESSER amount of line 5 or line 6d
(TC)
$
6.
Total net Arizona premium taxes (2003 Installment Tax Base)
(IB)
(line 3 minus line 5, but not less than zero)
8.
Total net Arizona premium taxes (2003 Installment Tax Base) (line 5
$
(IB)
minus line 7, but not less than zero)
7.
Less: 2002 Installment Taxes Paid (excluding penalty or interest)
$
9.
a) March 15, 2002
$
Less: 2002 Installment Taxes Paid (excluding penalty or interest)
b) April 15, 2002
$
a) March 15, 2002
$
c) May 15, 2002
$
b) April 15, 2002
$
c) May 15, 2002
d) June 15, 2002
$
$
d) June 15, 2002
e) July 15, 2002
$
$
e) July 15, 2002
f) August 15, 2002
$
$
f) August 15, 2002
(TIP)
g) Total of lines 7a through 7f
$
8.
Enter result of line 6 minus line 7g on line 8a if positive, or on 8b if negative.
g) Total of lines 9a through 9f
(TIP)
$
10.
a) Arizona premium tax due -carry to Part C, Page 1, line 2
Enter result of line 8 minus line 9g on line 10a if positive, or on 10b if negative.
(NT)
$
*
b) Overpayment of Arizona premium taxes - to be refunded
a) Arizona premium tax due -carry to Part C, Page 1, line 2
(SR)
(NT)
$
$
*
b) Overpayment of Arizona premium taxes - to be refunded
(SR)
$
*
Warning! DO NOT ATTEMPT TO APPLY A PREMIUM TAX OVERPAYMENT TO RETALIATORY TAXES OR ANNUAL FEES DUE WITH THIS REPORT. OVERPAYMENTS WILL BE REFUNDED WITHIN 90 DAYS
OF THE DUE DATE OF THIS REPORT. ANNUAL FEES AND RETALIATORY TAX MUST BE PAID WITH THIS RETURN.
CONTINUE TO PART C ON PAGE 1 FOR SUMMARY AND SIGNATURES
PENALTY FOR LATE PAYMENT OF TAX: Late Payment of tax is subject to a civil penalty equal to the greater of $25 or 5% of the tax paid late, plus interest of 1% per month from the date the tax was due.
E-ANNUALTAX (12/02)
PAGE 3 OF 3
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