Form E-Tax - Annual Tax And Fees Report Page 6
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9Name of Insurer
NAIC #
Domicile
Business Type Code
Entity Type Code
2 FIRE TAX ON PROPERTY, SUBJECTS OR RISKS IN “NON‐QUALIFIED LOCALES”
ARS § 20‐224(B) prescribes a 2.2% fire insurance tax rate for property located in Arizona for property outside qualified locales.
In Part 2, only report on insurance on property, subjects and risks located OUTSIDE Carefree and Fountain Hills, AZ
Description
Difference
(report portions of the total premiums attributable to covering fire
Original Report
Amended Report
risks)
(Amended – Original)
F1F
A. FIRE insurance premium
(100% of premium for non‐qualified
locales)
F1A
B. ALLIED LINES premium ‐ fire risk portion only
F1M
C. FARMOWNERS MULTIPERIL premium ‐ fire risk portion only
F1H
D. HOMEOWNERS MULTIPERIL premium ‐ fire portion only
F1C
E. COMMERCIAL MULTIPERIL premium ‐ fire portion only
F1W
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
outside qualified locales not included in Lines A through F
F1-g
H. GROSS QUALFIED FIRE PREMIUM REVENUE
(Sum of Lines A
0.00
0.00
0.00
through G)
I. Dividends to policyholders for insurance covering fire risks in
non‐qualified locales paid in cash or left on deposit that you
did not already subtract for Lines A through G
F1U
J. Other subtractions from taxable premiums for insurance
covering fire risks in non‐qualified locales that you did not
already subtract for Lines A through G. If not $0.00, you
must explain and provide documentation
F1-t
K. Taxable fire insurance premium revenue for non‐qualified
locales (Line H – Line I – Line J). Also enter this amount on
0.00
0.00
0.00
Schedule P, Line I.
F1T
L. NON‐QUALIFIED FIRE INSURANCE TAX
0.00
0.00
0.00
(Line K X 0.022)
M. EXPLANATIONS. Explain differences between amounts on this report and amounts in your annual statement, and provide any
other required explanation
3. TOTAL FIRE TAX
Difference
Description
Original Report
Amended Report
(Amended – Original)
F2T
0.00
0.00
0.00
a. QUALIFIED FIRE INSURANCE TAX (From Part 1, Line L)
F1T
0.00
0.00
b. NON‐QUALIFIED FIRE INSURANCE TAX (From Part 2, Line L)
0.00
FT
0.00
0.00
0.00
c. TOTAL FIRE INSURANCE TAX
(Line a + Line b)
ADOI — 03/08/13
11:21 am
Annual Tax and Fees Report: SCHEDULE F (2 of 2)
Form E‐TAX (v. 20130307)
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