Form E-Tax - Annual Tax And Fees Report Page 9

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INSURANCE TAX UNIT 
ANNUAL TAX AND FEES REPORT
Arizona Department of Insurance 
th
FORM E‐TAX | TRANSMITTAL
2910 North 44
 Street, Suite 210 
Phoenix, AZ 85018‐7269 
____
2012
for the calendar year ended December 31, 
Phone: (602) 364‐3997 | Fax (602) 364‐3989 
 
Name of Insurer 
NAIC # 
Dom 
Business Type 
Entity Type Code 
 
 
 
 
 
IMPORTANT!  YOU MUST INCLUDE THIS TRANSMITTAL FORM as part of your Form E‐TAX filing 
Part 1: Cash Receipts 
Type 
Gross 
Taxable 
Type 
Gross 
Taxable 
2012
0
0
0
0
C 
 
 
13 
PC 
 
 
WC 
 
 
0.01
0
0
Amt 
 
FC 
 
 
 
 
 
01
0
0
   Transaction Type: 
PCT 
 
 
 
 
 
0
0
PMT 
 
PCU 
 
 
 
 
 
0.01
30 
 
 
 
 
 
 
 
0
0
0
0
69 
 
F1 
 
 
AH 
 
 
0
0
0
0
Part 2: Revenue Distribution 
F1A 
 
 
FE 
 
 
0
0
0
0
2012
 
C 
 
13 
F1C 
 
 
GE 
 
 
0
0
0
0
0
Rnwl 
 
F1F 
 
 
MCX 
 
 
0
0
0
0
0
A/S 
 
F1H 
 
 
SG 
 
 
-0.01
0
0
0
0
Amt 
 
F1M 
 
 
AHU 
 
 
0
0
30
0
0
   Transaction Type: 
F1U 
 
 
AHT 
 
 
0
0
0
28 
 
F1W 
 
 
 
 
 
0
0
0
0
55 
 
F1T 
 
 
LI 
 
 
0
0
0
0
56 
 
F2 
 
 
AN 
 
 
0
0
0
0
58 
 
F2A 
 
 
LIU 
 
 
0
0
0
0
61 
 
F2C 
 
 
LT 
 
 
0
0
63 
 
F2F 
 
 
 
 
 
0
0
 
 
F2H 
 
 
 
 
 
0
0
0
04 
 
F2M 
 
 
 
 
 
0
0
0
05 
 
F2U 
 
 
 
 
 
0
0
0
07 
 
F2W 
 
 
 
 
 
0
0
0
09 
 
F2T 
 
 
 
 
 
0
0
 
 
FT 
 
 
 
 
 
-0.01
30 
 
 
 
 
 
 
 
0
0
0
0
46 
 
VE 
 
 
GT 
 
 
0
0
0
0
69 
 
VV 
 
 
TC 
 
 
0
0
0
0
99 
 
VM 
 
 
RT 
 
 
0
0
0
0
Part 3: Overpayment Refund 
VH 
 
 
TIP 
 
 
0
0
0
0
 
C 
 
13 
VC 
 
 
IB 
 
 
0
0
Amt 
 
VI 
 
 
 
 
 
0.00
0.00
0
0
   Transaction Type: 
VW 
 
 
RP 
 
 
0
0
SR 
 
VU 
 
 
 
 
 
0
0
RP / 99
 
VT
 
 
 
 
 
 
Department of Insurance – iSeries Premium Tax Database Batch Information: 
Part 1: Cash Receipts 
Part 2: Revenue Distribution 
Part 3: Overpayment Refund 
Date Received: 
Auditor: ______ 
Auditor: ______ 
Auditor: ______ 
 
Batch: 
Batch: 
Batch: 
ADOI — 03/08/13
11:21 am
 
Annual Tax and Fees Report: TRANSMITTAL 
Form E‐TAX (v. 20130307) 

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