Form E-Healthorg - Health Organization Annual Tax And Fees Report - Department Of Insurance State Of Arizona Page 2

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COMPANY NAME

NAIC NO.

PART A – ARIZONA HEALTH BUSINESS

IMPORTANT - Attach copies of the ARIZONA State Page 30 and Schedule T from your Health Annual Statement to this page.

COMPREHENSIVE MEDICAL

MEDICARE

GRAND TOTAL

Federal

Title XVIII

AHP Small

Medicare

All Other

Vision

Dental

Sum of Columns

Employees

Medicare

Individual

Group Only

Supplement

Other

Group

Only

B through J

Health

*Arizona Premium

Written (Annual

Statement Page 30,

0.00

line 12)

[FE Gross]

[

]

AH Gross]

SG Gross]

[GAH Gross

[MCX Gross

2. Exempt Premiums

0.00

(See Below)

Taxable Premium

]

[FE Tax = 0]

[MCX Tax=0]

GE Tax =0]

GE Tax = 0]

[SG Tax = 0

[GE Tax = 0

(line 1 minus line

0.00

xxxxxxxxxxxx

xxxxxxxxxxx

xxxxxxxxxxxx

[AH Tax]

[GAH Tax]

4. Tax Rate

2 %

Gross Tax Amount

[AHT]

0.00

(line 3 x line 4)

Carry to Page 3, line 1

* Refer to the applicable statute for the basis of premiums to be reported and provide a reconciliation schedule if the amounts reported on line 12, 13

and 14 on Page 30 of your Annual Statement differ from the amounts reported in Line 1, Page 2 of this report. Health Care Services Organizations

see ARS § 20-1060, Prepaid Dental Plan Organizations see ARS § 20-1010, and Hospital, Medical, Dental and Optometric Services Corporations see

ARS § 20-837.

LINE 2 EXEMPTIONS:

HOSPITAL, MEDICAL, DENTAL AND OPTOMETRIC SERVICE CORPORATIONS ONLY – ARS § 20-837, “the tax shall not apply with respect to any coverage

concerning which the corporation’s relationship is as administrative or fiscal agent for national, state or municipal government or any political subdivision or body thereof,

and such tax shall not apply with respect to any premiums received from funds of national, state or municipal government or any political subdivision or body thereof.”

Complete Form E-HEALTHORG.HMDO and enter the exempt amounts in the appropriate Columns on line 2, including Column A.

COLUMN C, LINES 1 AND 2 – AHP SMALL GROUP ONLY:

This Column should only be completed if the organization is an approved Accountable Health Plan (“AHP”) that issued “Health Benefit Plans” to “Small Employers” as

defined in ARS § 20-2301. THE ORGANIZATION MUST COMPLETE AND ATTACH FORM E-AHP TO SUPPORT THE CLAIMED EXEMPT PREMIUMS.

COLUMN F, FEDERAL EMPLOYEE HEALTH BENEFIT PLAN premiums are pre-empted from state tax under federal law. Enter your total FEHBP premiums on both

lines 1 and 2 of Column F and include it in lines 1 and 2 of Column A.

COLUMN G, Title XVIII MEDICARE funds are pre-empted from state tax under federal law. Attach a copy of the approval letter issued by CMS as a Medicare

Advantage Organization for this calendar year.

E-HEALTHORG (R

. 12/07)

ARIZONA DEPARTMENT OF INSURANCE

AGE