Form E-Fraternal - Annual Tax And Fees Report Foreign And Alien Life & Disability Insurer Fraternal Benefit Society - Az Department Of Insurance - 2002 Page 2

COMPANY NAME

NAIC NO.

2002 RETALIATORY TAXES AND FEES WORKSHEET

! C

MPORTANT

OMPLETE BOTH COLUMNS

In the State of Incorporation Column, enter the amounts that a like Arizona insurer would be required to pay to your state of incorporation, using the Arizona business as the base

amount for fees, assessments and taxes imposed. In the Arizona column, enter only amounts actually paid.

. F

TTACH TO THIS WORKSHEET PHOTOCOPIES OF PAYMENTS MADE

OR EXPLANATION AND CALCULATIONS FOR EACH ITEM REPORTED IN THIS WORKSHEET

AILURE TO

REPORT AND DOCUMENT RETALIATORY AMOUNTS MAY RESULT IN ASSESSMENTS INCLUDING APPLICABLE PENALTIES AND

OR INTEREST ON A RETALIATORY BASIS

State of Incorporation

Arizona

FEES:

(A)

(B)

Certificate of Authority renewal fee paid in 2002

30.00

Annual Statement filing fee paid in 2002

300.00

Publication fees paid in 2002

[ A

]

XXXXXXXXXXXXXX

TTACH

NVOICE

Policies, rates and forms filing fees

XXXXXXXXXXXXXX

Tax year 2002

Company agent license fees

[ S

E-AZ AGENTS ]

OOTNOTES BELOW AND ATTACH

ORM

a. Total number of Arizona agents licensed

$60.00

b. License fee per agent (Do not include late fees)

c. Total 2002 agent license fees ( 5a times 5b )

Column

See Footnotes below for lines 6 and 7

X’s

Enter Fee

XXXXXXXXXXXXXX

Company agent appointment fees

Amount

E-AZ AGENTS)

UST

TTACH

ORM

Enter Fee

XXXXXXXXXXXXXX

Company agent termination fees

Amount

E-AZ AGENTS)

UST

TTACH

ORM

Other fees (filing articles, bylaws, amendments)

SUBTOTAL #1 ( Add lines 1, 2, 3, 4, 5c, 6, 7, 8 )

ASSESSMENTS:

Fraud Fund Assessment

[ Attach Documentation ]

10.

Fraudulent Claims Assessment

XXXXXXXXXXXXXX

11.

XXXXXXXXXXXXXX

Health Care Appeals Fund Assessment

12.

Other Domiciliary Special Assessments

[ Attach Documentation ]

XXXXXXXXXXXXXX

13.

Other Domiciliary Assessments

[ Attach Documentation ]

XXXXXXXXXXXXXX

SUBTOTAL #2 ( Add lines 9 through 13 )

TAXES:

14.

State income tax paid/payable for 2002

[ Attach Pro Forma Return ]

15.

State income tax credit against premium tax for 2002

XXXXXXXXXXXXXX

(-)

16.

State franchise tax paid/payable for 2002

[ Attach Pro Forma Return ]

XXXXXXXXXXXXXX

17.

State franchise tax credit against premium tax for 2002

XXXXXXXXXXXXXX

(-)

18.

Other Domiciliary Taxes

[ Attach Documentation ]

XXXXXXXXXXXXXX

SUBTOTAL #3 ( Add lines 14 through 18 )

0.00

19.

RETALIATORY WORKSHEET TOTALS (Add Subtotals 1, 2 and 3)

( Enter line 19 amounts on Page 3, line 13 )

COMPANY AGENT FEES (Page 2, lines 5, 6, 7)

FOOTNOTE #1

ONLY INSURERS whose domiciliary state requires ARIZONA INSURERS to pay fees for the license, appointment or termination of their agent in that state noted on Lines 5

through 7, SHALL complete Form E-AZ AGENTS and attach to Form E-FRATERNAL. [P

LEASE CHECK YOUR DOMICILIARY STATE RETALIATORY GUIDE TO DETERMINE IF

.] We have identified the following states that require insurers to pay agent license, appointment or termination fees: Alabama, Arkansas, Connecticut, Delaware,

REQUIRED

North Carolina, North Dakota, Ohio, Tennessee and West Virginia however, the requirement may not be limited to these states.

All other insurers are exempt from retaliation for agent license fees only. Agent license fees for all other insurers are not applicable in the aggregate retaliatory calculation,

due to the absence of legal obligation or requirement by the domiciliary state for payment by the insurer.

Effective January 1, 1998 all Arizona Agent Licenses are renewed biennially. Only licenses renewed in 2002 should be entered in Column B, line 5a for the Calendar Year

FOOTNOTE #2

2002 by insurers who are domiciled in a state listed in FOOTNOTE #1 above.

COMPANY NAME

NAIC NO.

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 account of policies and contracts after deducting applicable cancellations, returned premiums, policy

E-FRATERNAL (R

. 12/02)

STATE OF ARIZONA

AGE

dividends, refunds, savings coupons and other similar returns paid or credited to policyholders and not reapplied as premiums for new, additional or extended

insurance.