Form E-Ar - Annual Fees Report - Arizona Department Of Insurance - 2000
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1ARIZONA DEPARTMENT OF INSURANCE
2000 ANNUAL FEES REPORT
DUE DATE: MARCH 1, 2001
FOREIGN AND ALIEN ACCREDITED REINSURER
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:
Toll Free or Collect Phone: (
)
FAX: (
)
Complete Mail Address:
112.50
1)
Certificate of Reinsurance Accreditation Renewal Fee
$
(Pay Code 58)
250.00
2)
Annual Statement Filing Fee
$
(Pay Code 28)
3)
TOTAL DUE MARCH 1, 2001
$
362.50
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AKE CHECK PAYABLE TO AND
Attention: TAX UNIT
:
MAIL CHECK WITH REPORT TO
2910 North 44
Street, Second Floor
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 the best
I certify that I have examined this report. It is true, complete and correct to the
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-AR (12/00)
PAGE 1 of 1
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