Form E-Title.domestic - Annual Fees Report Domestic Title Insurer - 2002
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1ARIZONA DEPARTMENT OF INSURANCE
2002 ANNUAL FEES REPORT
DUE DATE: MARCH 31, 2003
DOMESTIC TITLE INSURER
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
ARIZONA
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 A
- Enter Total Direct Arizona Premiums Written this calendar year
(TI GROSS/TAX)
PART B – SUMMARY OF ANNUAL FEES DUE MARCH 31, 2003
1)
Certificate of Authority Renewal Fee
$
135.00
(Pay Code 58)
2)
Annual Statement Filing Fee
$
300.00
(Pay Code 28)
3)
TOTAL DUE MARCH 31, 2003 – (DO NOT ROUND TO NEAREST DOLLAR)
$
435.00
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AKE CHECK PAYABLE TO
Attention: TAX UNIT
A
M
:
2910 North 44
Street, Second Floor
ND
AIL CHECK WITH REPORT TO
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
I certify that I have examined this report. It is true, complete and correct to the
the best of my knowledge.
best of my knowledge.
SIGNATURE OF PREPARER
DATE
SIGNATURE OF OFFICER
DATE
NAME AND TITLE TYPED OR PRINTED
NAME AND TITLE TYPED OR PRINTED
E-TITLE.D
(R
. 12/02)
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1
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OMESTIC
EV
AGE
OF
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