Form E-Fraternal - Annual Tax And Fees Report - Arizona Department Of Insurance - 2000 Page 2
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1
2
3COMPANY NAME
NAIC NO.
Total Arizona Premiums:
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 dividends, refunds, savings coupons and other similar returns paid or credited to
policyholders and not reapplied as premiums for new, additional or extended insurance.
PART A - 2000 RETALIATORY TAX COMPUTATION
(Important! Complete both columns and attach a copy of Arizona Business Page from the 2000 Annual Statement)
State of
Incorporation
Arizona
( A )
( B )
1.
Total Arizona Life Premiums
$
$
(FL gross/tax)
Less Deductions:
a) Paid in cash or left on deposit
(-)
b) Applied to pay renewal premiums (ONLY if included in line 1 above)
(-)
c) Other (SPECIFY)
(-)
2.
Net Taxable Life Premiums (line l minus la, lb, and lc)
$
3.
%
Life Premium Tax Rate
4.
Life Tax Due
$
5.
Total Arizona Annuity Considerations
(FA gross/tax)
$
$
Less Deductions (SPECIFY)
(-)
a)
b)
(-)
6.
Net Taxable Annuity Considerations (line 5 minus 5a and 5b)
$
7.
%
Annuity Consideration Tax Rate
8.
Annuity Tax Due
$
9.
Total Arizona Accident and Health Premiums
$
$
(FAH gross/tax)
Less Deductions (SPECIFY)
a)
(-)
b)
(-)
c)
(-)
10.
Net Taxable Accident & Health Premiums (9a minus 9a, 9b and 9c)
$
11.
%
Accident & Health Tax Rate
12.
Accident & Health Premium Tax Due
$
13.
Retaliatory Worksheet Totals (Page 3, line 19)
$
$
14.
Add lines 4, 8, 12, and 13
$
$
(DOM)
15.
Total of Arizona column, line 14
$
CANNOT BE
Retaliatory Tax Due (column A, line 14 minus line 15. If result is less than “0”,
NEGATIVE
16.
Carry to Page 1, Part B, line 1
enter “0”)
← ← ← ←
$
(RT gross/tax)
IMPORTANT NOTE: THE RETALIATORY AMOUNT DUE MAY NOT BE OFFSET IN ANY MANNER
E-FRATERNAL (12/00)
STATE OF ARIZONA
PAGE 2 of 3
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