Form E-Tax - Annual Tax And Fees Report Page 5
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9INSURANCE TAX UNIT
ANNUAL TAX AND FEES REPORT
Arizona Department of Insurance
FORM E‐TAX | SCHEDULE F
th
2910 North 44
Street, Suite 210
Phoenix, AZ 85018‐7269
(Fire)
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 F if you transacted fire insurance in Arizona.
Fire insurance includes premiums from mono‐line fire policies and the portions of other property and casualty premiums
attributable to covering fire risks. On SCHEDULE F, only report the amount of premiums attributable to covering fire risk.
Arizona law sets forth two different tax rates for fire insurance premiums. A 0.66% rate applies to premiums for insurance on
property located in cities and towns that procure the services of a private fire insurance company (Carefree and Fountain Hills),
referred to as “Qualified Locales.” A 2.2% rate applies to premiums for insurance on property located elsewhere within Arizona,
referred to as “Non‐qualified Locales.”
Complete the ‘Amended Report‘ and ‘Difference’ columns only if you are filing an amended report.
1. FIRE TAX ON PROPERTY, SUBJECTS OR RISKS IN “QUALIFIED LOCALES” (Carefree and Fountain Hills, AZ)
ARS § 20‐224(B) prescribes a 0.66% fire insurance tax rate for “…property located in an incorporated city or town certified by the
state fire marshal […] as procuring the services of a private fire company.” In Part 1, only report for Carefree or Fountain Hills, AZ
Description
Difference
(report portions of the total premiums attributable to covering fire
Original Report
Amended Report
risks)
(Amended – Original)
F2F
A. FIRE insurance premium
(100% of premium for qualified locales)
F2A
B. ALLIED LINES premium ‐ fire risk portion only
F2M
C. FARMOWNERS MULTIPERIL premium ‐ fire risk portion only
F2H
D. HOMEOWNERS MULTIPERIL premium ‐ fire portion only
F2C
E. COMMERCIAL MULTIPERIL premium ‐ fire portion only
F2W
F. AGGREGATE WRITE‐INS premium – fire portion only
G. Finance and service charges, membership fees, other fees
and other considerations for insurance covering fire risk in
qualified locales not included in Lines a through f
F2-g
H. GROSS QUALFIED FIRE PREMIUM REVENUE
(Sum of Lines A
0.00
0.00
0.00
through G)
I. Dividends to policyholders on insurance covering fire risks in
qualified locales paid in cash or left on deposit that you did
not already subtract for Lines A through G.
F2U
J. Other subtractions from taxable premiums for insurance
covering fire risks in qualified locales that you did not
already subtract for Lines A through G. If not $0.00, you
must explain and provide documentation
F2-t
K. Taxable fire insurance premium revenue for qualified locales
(Line H – Line I – Line J). Also enter this amount on Schedule
0.00
0.00
0.00
P, Line H.
F2T
0.00
0.00
0.00
L. QUALIFIED FIRE INSURANCE TAX
(Line K X 0.0066)
M. 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 F (1 of 2)
Form E‐TAX (v. 20130307)
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