Form E-Tax - Annual Tax And Fees Report Page 3
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9INSURANCE TAX UNIT
ANNUAL TAX AND FEES REPORT
Arizona Department of Insurance
FORM E‐TAX | SCHEDULE L
th
2910 North 44
Street, Suite 210
Phoenix, AZ 85018‐7269
(Life)
2012
____
Phone: (602) 364‐3997 | Fax (602) 364‐3989
for the calendar year ended December 31,
Name of Insurer
NAIC #
Domicile
Business Type Code
Entity Type Code
Only submit SCHEDULE L if the insurer transacted life insurance in Arizona.
Complete the ‘Amended Report‘ and ‘Difference’ columns only if you are filing an amended report.
"Arizona life insurance" includes ► individual policies and non‐employer group policies covering individuals or members whose
primary residence is in Arizona, ►credit insurance paid by Arizona residents, and ►employer group policies covering individuals
or members whose primary residence is in Arizona or whose primary workplace is in Arizona. EXCLUDE annuity considerations and
deposit‐type contract funds.
Difference
Description
Original Report
Amended Report
(Amended – Original)
A. Total Arizona annuity considerations (for informational
purposes only – not subject to tax in Arizona)
B. Total Arizona life insurance direct premiums
C. Finance and service charges, membership fees, and other
fees and considerations for Arizona life insurance not
included in Line A
LI-g
0.00
0.00
0.00
D. GROSS LIFE PREMIUM REVENUE
(Line B + Line C)
E. Dividends to policyholders for Arizona life insurance paid in
cash or left on deposit that you did not already subtract in
your calculation for Line A
F. Cancellations, return premiums, refunds, savings coupons
and other similar returns to policyholders not reapplied as
premiums that you did not already subtract from Line A
LIU
G. Other subtractions from taxable premiums that you did not
already subtract for Lines B through F. If not $0.00, you
must explain and provide documentation
LI-t
H. Taxable life insurance premium revenue
(Line D – Line E – Line
0.00
0.00
0.00
F – Line G)
LT
0.00
0.00
0.00
I. LIFE INSURANCE TAX
(Line H X 0.02)
J. EXPLANATIONS. Explain differences between amounts on this report and amounts in your annual statement, and provide any
other required explanation and documentation
ADOI — 03/08/13
11:21 am
Annual Tax and Fees Report: SCHEDULE L
Form E‐TAX (v. 20130307)
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