Form E-Indins - Industrial Insured Premium Receipts Tax Report For The Period Of January 1 - July 20, 2011
Download a blank fillable Form E-Indins - Industrial Insured Premium Receipts Tax Report For The Period Of January 1 - July 20, 2011 in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form E-Indins - Industrial Insured Premium Receipts Tax Report For The Period Of January 1 - July 20, 2011 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5INSURANCE TAX UNIT
INDUSTRIAL INSURED
Mail/deliver to:
Arizona Department of Insurance
PREMIUM RECEIPTS TAX
2910 North 44th Street, Suite 210
REPORT (
ARS § 20-401.07)
Phoenix, AZ 85018-7269
for the period of
Phone: (602) 364-3246 | Fax: (602) 364-3989
JANUARY 1 - JULY 20, 2011
Web:
Original Filing
Amended Filing
By March 1, 2012, use this form to report insurance that you procured from unauthorized insurers during
the period of January 1 through July 20, 2011.
By or before new due dates established in Laws 2011, Ch. 136 (House Bill 2112), use Form E-II to report
insurance that you procured from unauthorized insurers from and after July 21, 2011. The new due
dates are listed within Form E-II.
Print Form
Clear Form
TAX UNIT:II#-
SECTION A: CONTACT INFORMATION
Complete Name of Insured
FEIN
Insured's Principal Address
City
State
ZIP Code
Preparer's Name
Preparer's Title
Preparer's Phone Number
Preparer's E-mail Address
SECTION B: TAX AMOUNT DUE
TAX UNIT: C/L/U/N-U, NAIC-5499, Period-13, TransType-
$0.00
II
B1
Sum of [premium amount times "% in AZ"] from Section F, Box F9c
$0.00
Ø8
B2
Tax due = Line B1 X 3%. Make payment out to AZ Dept of Insurance.
Or beroSECTION C: INDUSTRIAL INSURED QUALIFICATIONS. Prior to July 21, 2011, you must have met at
least two of the following qualifications to be an industrial insured. If you did not meet at least two qualifications,
you must file this report and cease procuring insurance directly from non-admitted insurers. You may use an
Arizona-licensed surplus lines broker for insurance from non-admitted insurers.
IMPORTANT! The definition of "industrial insured" changed effective July 21, 2011. New qualifications are
reflected in Section C of Form E-II.
C1
During the most recently ended fiscal year:
Complete C1a and C1b
a.
Did the insured apply for or procure property and/or casualty
insurance subject to ARS Title 20, Ch. 2, Art. 4.1, with annual gross
premiums totaling at least $100,000?
Yes
No
b.
What was the total of aggregate annual gross premiums paid for
insurance on all property and casualty risks that are subject to ARS
Title 20, Ch. 2, Art. 4.1?
___________________
C2
As of the end of the most recent fiscal year:
Complete C2a and C2b
a.
Did the insured possess a net worth of over $10 million as verified
by a certified public accountant?
Yes
No
b.
What was the amount of the insured's net worth
___________________
C3
During the most recently ended fiscal year, did the insured have net
Yes
No
revenues or sales exceeding $25 million as verified by a CPA?
C4
As of the issuance date for each policy the insured purchased from an
Yes
No
unauthorized insurer (to be reported in Section F), did the insured have
more than 80 full-time employees or equivalent, or 100 full-time employees
or equivalent per holding company system?
Form E-IndIns (v20111027)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form It-40pnr - Schedule Ct-40pnr - County Tax Schedule For Part-year And Full-year Indiana Nonresidents - 2011
Financial
Form It-141 - West Virginia Fiduciary Income Tax Return (for Resident And Non-resident Estates And Trusts) - 2011
Financial
Related Categories
Parent category: Financial