Form E-Fraternal - Annual Tax And Fees Report Foreign And Alien Life & Disability Insurer Fraternal Benefit Society - Az Department Of Insurance - 2002
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3ARIZONA DEPARTMENT OF INSURANCE
2002 ANNUAL TAX AND FEES REPORT
DUE DATE: MARCH 1, 2003
FOREIGN AND ALIEN LIFE & DISABILITY INSURER
FRATERNAL BENEFIT SOCIETY
PREMIUM TAX UNIT
(602) 912-8429
FAX (602) 912-8421
For Office Use Only
For Audit Use Only
ORIGINAL REPORT
________________________________________________________________________________________________
AMENDED REPORT / REASON
Complete Company Name and Home Office Address
State of Incorporation
x
x
x
NAIC Number
x
NAIC Group Number
x
Federal I. D. Number
x
Preparer’s Name and Title:
E-Mail Address:
Toll Free or Collect Phone: (
)
FAX: (
)
Complete Mail Address:
PART B – SUMMARY OF TAXES AND FEES DUE MARCH 1, 2003
1)
Retaliatory Amount (Part A, Page 3, line 16 – not less than zero)
$
(Pay Code 04)
2)
Certificate of Authority Renewal Fee
$
30.00
(Pay Code 54)
3)
Annual Statement Filing Fee
$
300.00
(Pay Code 28)
4)
TOTAL DUE MARCH 1, 2003 – NOT LESS THAN $330.00
$
(Add lines 1 through 3, above – DO NOT ROUND TO NEAREST DOLLAR)
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AKE CHECK PAYABLE TO AND
Attention: TAX UNIT
M
:
2910 North 44
Street, Second Floor
th
AIL CHECK WITH REPORT TO
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 best of
I certify that I have examined this report. It is true, complete and correct to the best of
my knowledge.
my knowledge.
SIGNATURE OF PREPARER
DATE
SIGNATURE OF OFFICER
DATE
NAME AND TITLE TYPED OR PRINTED
NAME AND TITLE TYPED OR PRINTED
E-FRATERNAL (R
. 12/02)
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EV
AGE
OF
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