Form E-Tax - Annual Tax And Fees Report
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9INSURANCE TAX UNIT
ANNUAL TAX AND FEES REPORT
Arizona Department of Insurance
FORM E‐TAX
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2910 North 44
Street, Suite 210
Phoenix, AZ 85018‐7269
_____
2012
for the calendar year ended December 31,
Phone: (602) 364‐3997 | Fax (602) 364‐3989
Original Report Amended Report
1. INFORMATION ABOUT THE INSURER
► Open the Annual Taxes and Fees Data Sheet and locate the insurer's data sheet page.
►Go to
►Enter the insurer’s name, domicile and business type exactly as they appear in the insurer’s record on the data sheet page.
Name of Insurer
NAIC #
Domicile
Business Type Code
Entity Type Code
Federal I.D. Number
Mailing Address for Tax/Fee Refunds
City
State
ZIP Code
2. INFORMATION ABOUT THE REPORT PREPARER
Name of Report Preparer
Preparer’s E‐mail Address
Phone Number
Fax Number
Mailing Address
City
State
ZIP Code
PREPARER’S ATTESTATION:
By signing or electronically submitting this Report, I hereby certify that this Report, including but not limited to any
forms, statements, schedules, spreadsheets, worksheets and other documentation, is true, complete and correct.
Preparer’s Signature
Date
(not required if electronically submitting via OPTins)
3. SUMMARY OF FEES, TAXES AND RETALIATION
NOTE: Only complete the ‘Amended Report‘ and ‘Difference’ columns if you are filing an amended report.
Difference
Description
Original Report
Amended Report
(Amended – Original)
LT
0.00
0.00
0.00
A. Life Insurance Tax from SCHEDULE L
AHT
0.00
0.00
0.00
B. Accident & Health Insurance Tax from SCHEDULE H
FT
0.00
0.00
0.00
C. Fire Insurance Tax from SCHEDULE F
VT
0.00
0.00
0.00
D. Vehicle Insurance Tax from SCHEDULE V
PCT
0.00
0.00
0.00
E. Other Property & Casualty Insurance Tax from SCHEDULE P
GT
0.00
0.00
0.00
F. Premium Taxes Before Credits
(Sum Lines A through E)
TC
G. Tax Credits and Offsets from FORM E‐TC
H. Tax Liability
(Line F – Line G). If this amount is $2,000 or more,
you must make installment payments during _______. See Form E‐
2013
0.00
0.00
0.00
INSTALL instructions for details.
0.00
0.00
0.00
I. Certificate of Authority Renewal Fee
0.00
0.00
0.00
J. Annual Statement Filing Fee
RT
K. Retaliation from the FORM E‐RT for your domicile
(enter
$0.00 for an Arizona‐domiciled insurer)
0.00
0.00
0.00
L. Total Taxes, Fees and Retaliation
(Sum Lines H through K)
0.00
0.00
TIP
0.00
M. Installments Paid in ______ from SCHEDULE I
2012
N. If filing an amended report, enter the amount you paid with
0.00
0.00
your previously filed report
O. If filing an amended report, enter the total refund you
0.00
0.00
received from your previously filed report
PMT
P. AMOUNT DUE OR OVERPAID
(Line L– Line M – Line N + Line O).
RP
►If greater than $0.00, pay the AMOUNT DUE.
0.00
0.00
0.00
►If less than $0.00, we will refund the amount you overpaid.
ADOI — 03/08/13
11:21 am
Annual Tax and Fees Report
Form E‐TAX (v. 20130307)
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