2004 Annual Tax And Fees Report - Arizona Department Of Insurance
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1
2
3DEPARTMENT OF INSURANCE
STATE OF ARIZONA
FINANCIAL AFFAIRS DIVISION - TAX UNIT
th
2910 North 44
Street, Suite 210
Phoenix, Arizona 85018-7256
Phone: (602) 912-8429 Fax: (602) 912-8421
HEALTH CARE SERVICES
PREPAID DENTAL PLAN
HOSPITAL, MEDICAL, DENTAL AND
ORGANIZATION
ORGANIZATION
OPTOMETRIC SERVICE CORPORATION
2004 ANNUAL TAX AND FEES REPORT
DUE MARCH 1, 2005
ORIGINAL REPORT
AMENDED REPORT / REASON______________________________________________________________________________________
Complete Company Name and Home Office Address
State of Incorporation
X
X
x
NAIC Number
x
NAIC Group Number
x
Federal I. D. Number
x
Preparer’s Name and Title:
E-Mail Address:
Toll Free or Collect Phone: (
)
FAX: (
)
Complete Mail Address:
PART C – SUMMARY OF TAXES AND FEES DUE
1)
Tax Due (Part B, Page 3, line 4a – not less than zero)
$
(Pay Code 07)
2)
Certificate of Authority Renewal Fee
$
75.00
(Pay Code 63)
3)
Annual Statement Filing Fee
$
300.00
(Pay Code 28)
4)
TOTAL DUE (Add lines 1 through 3) - NOT LESS THAN $375.00
$
PAYMENT OPTIONS –
ONLY ONE
:
CHECK
OPTION FOR REMITTANCE OF THE AMOUNT DUE ABOVE
-
.
ACH DELIVERY IN ACCORDANCE WITH THE FORMAT AND CONTENT PRESCRIBED IN FORM E
ACH
INSTRUCTION
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F
I
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S
U
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A
N
C
E
IS ENCLOSED WITH THIS REPORT.
CHECK PAYABLE TO
MAIL THIS REPORT TO:
Attention: TAX UNIT
2910 North 44
Street, Suite 210
th
Phoenix, Arizona 85018-7256
PREPARER CERTIFICATION
COMPANY OFFICER CERTIFICATION
I certify that I have prepared this report. It is true, complete and correct to the
I certify that I have examined this report. It is true, complete and correct to the
best of my knowledge.
best of my knowledge.
SIGNATURE OF PREPARER
DATE
SIGNATURE OF OFFICER
DATE
NAME AND TITLE TYPED OR PRINTED
NAME AND TITLE TYPED OR PRINTED
E-HEALTHORG (R
. 12/04)
P
1
3
EV
AGE
OF
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