Form E-Sl-2 - Arizona Licensed Surplus Lines Broker Semi-Annual Statement And Premium Tax Report - 2006

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DEPARTMENT OF INSURANCE
Reset
STATE OF ARIZONA
Financial Affairs Division – Tax Unit
th
2910 North 44
Street, Suite 210
Phoenix, Arizona 85018-7269
Phone: (602) 364-3998
Fax: (602) 364-3989
ARIZONA LICENSED SURPLUS LINES BROKER
SEMI-ANNUAL STATEMENT AND PREMIUM TAX REPORT
July 1, 2006 through December 31, 2006
READ FORM E-SL.INSTRUCTION “ARIZONA LICENSED SURPLUS LINES BROKER SEMI-ANNUAL STATEMENT AND PREMIUM
TAX REPORT FILING INSTRUCTIONS” BEFORE PROCEEDING TO PREPARE AND FILE THIS REPORT.
A “NONE” REPORT IS NOT REQUIRED TO BE FILED IF THERE WERE NO (NEW, RENEWAL OR CANCELLATION)
TRANSACTIONS PERFORMED BY THE BROKER WITH EFFECTIVE DATES THAT FALL WITHIN THE SEMI-ANNUAL PERIOD
SPECIFIED ABOVE.
AMENDED REPORTS MUST BE FILED ON FORM E-SL-AMEND.
Arizona License Number
Name on License
Mailing Address
Telephone #:
FAX #
E-Mail Address:
PART B - AFFIDAVIT OF BROKER UNDER OATH
** This Affidavit must be executed and notarized to be considered a complete filing **
OATH
State of
ss
}
County of
}
I ________________________________________________, being duly sworn, depose and say that I am now, or was
(Type or Print Complete Name of Affiant)
during the preceding six months, a duly licensed Arizona Surplus Lines Broker, or, I am duly authorized to execute this
statement on behalf of the licensed firm named below in my capacity as
(Title)
and that the information contained in Part A on Page 2 of this report, including any attachments thereto, is complete, true
and correct to the best of my knowledge and belief.
Type Name of Licensed Firm, if applicable:
Signature of Affiant Broker or Authorized
Official on behalf of a Licensed Firm
Subscribed and sworn to before me this _________ day of ________________________ , _________.
SEAL
(
)
My commission expires:
(Notary Public)
PAYMENT OPTIONS – CHECK ONE OPTION BELOW FOR PAYMENT OF THE TAX DUE (PAGE 2, LINE 4):
(
)
-
.
ACH DELIVERY
OPTION AVAILABLE TO FIRMS ONLY
USE FORMAT AND CONTENT PRESCRIBED IN FORM E
ACH
INSTRUCTION
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CHECK PAYABLE TO
MAIL THIS REPORT (WITH CHECK, IF APPLICABLE) TO THE ADDRESS SHOWN ABOVE
E-SL-2 (R
. 1/07)
P
1
2
EV
AGE
OF

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