Looking for a Arizona Tax Forms And Templates? Download it for free!

ARIZONA DEPARTMENT OF INSURANCE

Financial Affairs Division

COMPLIANCE SECTION

2910 NORTH 44TH STREET, SECOND FLOOR

Phoenix, Arizona 85018-7256

Phone: (602) 912-8427 Fax: (602) 912-8421

ATTENTION: FORMERLY LICENSED SURPLUS LINES BROKER

FINAL STATEMENT AND PREMIUM TAX REPORT FORMS INVENTORY AND INSTRUCTIONS

FORM NAME

FORM DESCRIPTION

E-SLB-F

Final Surplus Lines Broker Statement and Premium Tax Report

INAL

E-SLB-F

-RPG

Final Surplus Lines Broker Statement of Risk Purchasing Group Placements

INAL

LL FORMS ARE DUE WITHIN

DAYS OF THE SURPLUS LINES BROKER LICENSE TERMINATION

WHO MUST FILE: Any individual person or corporation that held a Surplus Lines Broker license issued by this Department, which was

nonrenewed or was revoked or voluntarily terminated, MUST complete and file a Final Statement and Premium Tax Report Form E-SLB-

INAL

HOW TO COMPLETE THE REPORT FORM E-SLB-F

: The following information must be included within Report Form E-SLB-F

INAL

be in compliance with the reporting and tax remittance requirements:

•

The REPORTING PERIOD and DATE OF LICENSE TERMINATION must be specified. The REPORTING PERIOD must commence

with either January 1 or July 1 for the current or most recent Semi-Annual reporting period and must end with the date of License

Termination. For example, if your license terminated on November 30

the Reporting Period begins July 1 and ends November 30

with the filing and tax payment due December 30

•

The EXHIBIT OF SURPLUS LINES PREMIUMS must be fully completed. DO NOT round numbers. Enter “0” or “NONE” in all

spaces where applicable. DO NOT file a BLANK Statement, as it will not fulfill the reporting requirement. PREMIUMS MUST BE

REPORTED IN A MANNER CONSISTENT WITH SUBMISSIONS TO THE SURPLUS LINES ASSOCIATION OF ARIZONA.

Taxable premiums include policy fees, other than stamping fees, which are payable to the Surplus Lines Association of

Arizona.

•

The FIRE PORTION OF NET PREMIUMS must be provided to enable the Department to allocate fire premium tax revenues to the

Fire Fighters Relief and Pension Fund. The Surplus Lines Association of Arizona can provide standard apportionment percentages by

lines of business to assist in reporting this information.

•

FORM E-SLB-F

.RPG LISTING ALL RISK PURCHASING GROUPS for which liability insurance as defined by A.R.S. § 20-

INAL

2401(5) and U.S.C. 3901(a)(2)(A) was placed with qualified Surplus Lines Insurers must be attached if premiums are reported in this

category on Form E-SLB-F

INAL

•

THE AFFIDAVIT OF BROKER UNDER OATH must be executed and notarized in order for your Final Statement and Premium Tax

Report to be considered acceptable.

•

PREMIUM TAX REMITTANCE must be payable to the Arizona Department of Insurance and must accompany the Report Form E-

SLB-F

. DO NOT combine payments for more than one filing. Each licensed broker must report and remit tax payments due

INAL

separately.

DUE DATE: The Final Statement and Premium Tax Report Form E-SLB-F

, Form E-SLB-F

.RPG (if applicable) AND payment of the

INAL

tax is due 30 days from date of termination of the Surplus Lines Broker license. *

Mailing - Postmark Policy - This Department honors validation or postmark by the U.S. Postal Service as evidence of filing. POSTAGE

METER STAMPS DO NOT APPLY.

Courier or Hand-Delivery - Filings received by courier must include an invoice or receipt which bears the date that the item was picked up by

the courier from the originating sender. Personal hand-deliveries to the Department must be received before 5:00 P.M. on the 30

day. *

* If the 30

day falls on a Saturday or Sunday, the due date is extended to the following Monday.

E-SLB-F

(07/04)

INAL

NSTRUCTION

AGE

Final Statement And Premium Tax Report Forms Inventory And Instructions - Arizona Department Of Insurance

Related Articles

Related forms

Related Categories