Form E-159ms - Nonresident Surplus Lines Broker Statement And Tax Payment

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DEPARTMENT OF INSURANCE
ARIZONA
Financial Affairs Division
COMPLIANCE SECTION
2910 NORTH 44TH STREET, SECOND FLOOR
Phoenix, Arizona 85018-7256
Phone: (602) 912-8427 Fax: (602) 912-8421
NONRESIDENT SURPLUS LINES BROKER STATEMENT AND TAX PAYMENT
FOR THE ARIZONA PORTION OF A MULTI-STATE SURPLUS LINES TRANSACTION
A.R.S. §§ 20-411.02(C) and 20-416(C)
See Instruction Form E-159MS.I
to complete this form
NSTRUCTION
State of Residence
State of Residence License #
Name on License
Mailing Address
Telephone #
(
)
FAX #
(
)
E-Mail Address:
STATEMENT OF SURPLUS LINES PREMIUMS ALLOCABLE TO ARIZONA For Reporting Period of: _____________________
A
B
C
D
E
Line of Business
Aggregate Gross
Return Premiums
Aggregate
Fire Portion
Description
Premiums Charged
Paid to Insureds
Net Premiums
1. Disability (includes accident)
$
(-)$
= $
XXXXXXXXX
[DA Gross]
[DA Tax]
2. Property - Fire
$
(-)$
= $
[PF Gross]
[PF Tax]
3. Property - All Other
$
(-)$
= $
[PO Gross]
[PO Tax]
4. Marine & Inland Transportation
$
(-)$
= $
[MT Gross]
[MT Tax]
5. Vehicle - Aircraft
$
(-)$
= $
[VA Gross]
[VA Tax]
6. Vehicle - Land
$
(-)$
= $
[VL Gross]
[VL Tax]
XXXXXXXXX
7. Casualty
$
(-)$
= $
[C Gross]
[C Tax]
XXXXXXXXX
8. Surety
$
(-)$
= $
[S Gross]
[S Tax]
9. Purchasing Groups (Attach List)
$
(-)$
= $
XXXXXXXXX
[PG Gross]
[PG Tax]
10. Other - Describe
$
(-)$
= $
XXXXXXXXX
[OT Gross]
[OT Tax]
11. TOTAL OF ALL COLUMNS
$
(-)$
= $
$
[SL Gross]
[SL Taxable]
[SLF Gross/Tax]
12. Surplus Lines Tax Rate
3%
Make Check Payable to:
"Arizona Department of
Pay this amount:
Insurance"
= $
13. SURPLUS LINES PREMIUM TAX DUE (Column D, Line 11 x 0.03)
Send to Address Above
This report has been prepared in accordance with the provisions of A.R.S. §§ 20-411.02(C) and 20-416(C) for surplus lines insurance procured in another state by
the nonresident broker named above, of which 50% or less of the exposure is allocable to properties or operations in Arizona.
Signature of Broker Named Above
Date Prepared
E-159MS (R
. 07/04)
P
1
1
EV
AGE
OF

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