Form E-Tax - Annual Tax And Fees Report Page 4
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9INSURANCE TAX UNIT
ANNUAL TAX AND FEES REPORT
Arizona Department of Insurance
FORM E‐TAX | SCHEDULE H
th
2910 North 44
Street, Suite 210
Phoenix, AZ 85018‐7269
(Accident & Health)
____
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
Submit SCHEDULE H if you transacted accident and health insurance in Arizona, even if you are a property and casualty insurer.
Complete the ‘Amended Report‘ and ‘Difference’ columns only if you are filing an amended report.
"Arizona accident and health (“A & H”) insurance" includes ► insurance premiums covering subjects or risks located, resident or
to be performed in Arizona [ARS § 20‐224], ► net service corporation premiums for subscription contracts [ARS § 20‐837], ► net
prepaid dental organization members charges [ARS § 20‐1010]; ► net health care services organization enrollee charges [ARS
§ 20‐1060]; and, ►credit A & H insurance paid by Arizona residents.
Difference
Description
Original Report
Amended Report
(Amended – Original)
A. Arizona A & H insurance premiums.
B. Finance and service charges, membership fees, and other
fees and considerations for Arizona A & H insurance not
included in Line a
AH-g
0.00
0.00
0.00
C. GROSS A & H PREMIUM REVENUE
(Line A + Line B)
D. Dividends to policyholders for Arizona A & H insurance paid
in cash or left on deposit that you did not already subtract in
your calculation for Line A
FE
E. Federal Employee Health Benefits Program premium not
already subtracted in Line A
MCX
F. Medicare Advantage Plan (Title XVIII) tax‐exempt premiums
not already subtracted from Line A
GE
G. If insurer is a service corporation, federal, state and
municipal government premiums not already subtracted
from Line A; else, enter $0.00
SG
H. If insurer is an accountable health plan, small employer
health benefit plan premiums from the SGHI.XLS workbook.
AHU
I. Other subtractions from taxable premiums that you did not
already subtract for Lines A through H. If not $0.00, you
must explain and provide documentation
AH-t
J. TAXABLE A & H INSURANCE PREMIUM REVENUE
(Line C – Line
0.00
0.00
0.00
D – Line E – Line F – Line G – Line H – Line I)
AHT
0.00
0.00
0.00
K. ACCIDENT & HEALTH INSURANCE TAX
(Line J X 0.02)
L. EXPLANATIONS. Explain differences between amounts on this report and amounts in your annual statement, and provide any
other required explanation
ADOI — 03/08/13
11:21 am
Annual Tax and Fees Report: SCHEDULE H
Form E‐TAX (v. 20130307)
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