Form E-Tax - Annual Tax And Fees Report Page 8
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9INSURANCE TAX UNIT
ANNUAL TAX AND FEES REPORT
Arizona Department of Insurance
FORM E‐TAX | SCHEDULE P
th
2910 North 44
Street, Suite 210
Phoenix, AZ 85018‐7269
(Other Property & Casualty)
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 P if you transacted property or casualty (“P & C”) insurance.
Complete the ‘Amended Report‘ and ‘Difference’ columns only if you are filing an amended report.
Do not subtract vehicle insurance premiums reported on Schedule V from amounts reported on this Schedule. Vehicle insurance is
subject to both, the property and casualty tax and the “additional tax” on insurance covering vehicles.
Difference
Description
(Amended –
(Net direct premiums written = DPW minus dividends)
Original Report
Amended Report
Original)
A. Total Arizona direct written premiums for ALL types of
insurance
B. Total finance and service charges, membership fees, and
other fees and considerations not included in Line A
0.00
0.00
0.00
C. Gross A & H premium from SCHEDULE H, Line C
PC-g
0.00
0.00
0.00
D. GROSS P & C PREMIUM REVENUE
(Line A + Line B – Line C)
E. Dividends to policyholders paid in cash or left on deposit
that you did not already subtract in your calculation for Line
A
FC
F. Crop and hail insurance premiums reinsured by the FCIC
WC
G. Workers compensation insurance premiums that were
taxed by the Industrial Commission of Arizona (must be
$0.00 or greater – do not enter a negative amount even if
the insurer had net negative workers’ compensation
premiums)
PCU
H. Other subtractions from taxable premiums that you did not
already subtract for Lines A through C. If not $0.00, you
must explain and provide documentation
I. Taxable fire insurance premium revenue for qualified locales
0.00
0.00
0.00
from SCHEDULE F, Part 1, Line K
J. Taxable fire insurance premium revenue for non‐qualified
0.00
0.00
0.00
locales from SCHEDULE F, Part 2, Line K
PC-t
K. Taxable P & C insurance premium revenue
(Line D – Line E
0.00
0.00
0.00
– Line F – Line G – Line H – Line I – Line J)
PCT
0.00
0.00
0.00
L. PROPERTY & CASUALTY INSURANCE TAX
(Line K X 0.02)
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 P
Form E‐TAX (v. 20130307)
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