Form E-Tax - Annual Tax And Fees Report Page 7
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9INSURANCE TAX UNIT
ANNUAL TAX AND FEES REPORT
Arizona Department of Insurance
FORM E‐TAX | SCHEDULE V
th
2910 North 44
Street, Suite 210
Phoenix, AZ 85018‐7269
(Vehicle)
____
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 V if you transacted insurance carried for or on vehicles in Arizona.
On SCHEDULE V, only report the amount of premiums attributable to covering vehicles.
Complete the ‘Amended Report’ and ‘Difference’ columns only if you are filing an amended report.
ARS § 20‐224.01 prescribes a 0.4312% “additional premium tax” for insurance carried for or on vehicles. The tax calculated on this
schedule is in addition to the tax applied on Schedule P (Property and Casualty); therefore, do not subtract the premiums reported
on this schedule from amounts you report on Schedule P.
Description
Difference
(report portions of the total premiums attributable to covering
Original Report
Amended Report
vehicles)
(Amended – Original)
VV
A. AUTOMOBILE INSURANCE premium
(State Page Exhibit, Lines 19.1 through 19.4, and 21.1 and 21.2)
VM
B. FARMOWNERS MULTIPERIL premium – vehicle risk portion
only
VH
C. HOMEOWNERS MULTIPERIL premium – vehicle risk portion
only
VC
D. COMMERCIAL MULTIPERIL premium – vehicle risk portion
only
VI
E. INLAND MARINE premium – vehicle risk portion only
VW
F. AGGREGATE WRITE‐INS premium – vehicle risk portion only
G. Finance and service charges, membership fees, other fees
and other considerations for insurance on or for vehicles not
included in Lines A through F
VE-g
H. GROSS VEHICLE PREMIUM REVENUE
(Sum of Lines A through
0.00
0.00
0.00
G)
I. Dividends to policyholders for insurance on or for vehicles
paid in cash or left on deposit that you did not already
subtract in your calculations for Lines A through F
VU
J. Other subtractions from taxable premiums that you did not
already subtract for Lines A through F. If not $0.00, you
must explain and provide documentation
VE-t
K. Taxable vehicle insurance premium revenue (Line H – Line I
0.00
0.00
0.00
– Line J)
VT
0.00
0.00
0.00
L. ADDITIONAL TAX ON VEHICLE INSURANCE
(Line K X 0.004312)
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 V
Form E‐TAX (v. 20130307)
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