Form E-Rg - Foreign Risk Retention Group Annual Tax Report

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Department of Insurance
FOREIGN RISK RETENTION GROUP
State of Arizona
ANNUAL TAX REPORT
Financial Affairs Division – Tax Unit
Reset
DUE MARCH 1
2910 North 44th Street, Suite 210
Phoenix, AZ 85018-7269
Telephone: (602) 364-3997
ENTER THE CALENDAR YEAR OF
Facsimile: (602) 364-3989
THIS REPORT _________
ORIGINAL REPORT
AMENDED REPORT / REASON
TC 01
TC 02
Complete Company Name and Mail Office Address
State of Incorporation (Domicile)
X
X
X
NAIC Number:
X
Federal I. D. Number:
X
Phone:
Preparer’s Name and Title:
Preparer’s Mail Address:
Preparer’s Toll Free/Collect Phone:
E-Mail Address:
FAX:
Enter your initials and the date to certify that this report is
true, complete and correct to the best of your knowledge
Initials
Date
Click a YES or NO response to each question below before proceeding to Page 2
Responses may label certain pages of this report as “NOT REQUIRED”
YES
NO
Are you incorporated (domiciled) in: AL, FL, GA, IL, KY, LA, MO, NE, NY, PA, SC or WV?
Did you write any vehicle insurance coverage in Arizona?
Did you make contributions to a School Tuition Organization in Arizona?
Does your state of incorporation (domicile) require Arizona insurers to pay:
a. Appointment fees for its agents in your state?
b. Termination fees for its agents in your state?
Continue to Page 2
E-RG
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