INSURANCE TAX UNIT INSTALLMENT PAYMENT REPORT
Arizona Department of Insurance
2910 North 44th Street, Suite 210
Phoenix, AZ 85018-7269 For installments paid in
Phone: (602) 364-3997| FAX: (602) 364-3989
CALENDAR YEAR _______
INFORMATION ABOUT THE INSURER
Name of Insurer NAIC # Domicile* State
INFORMATION ABOUT THE REPORT PREPARER:
Preparer’s Name Preparer’s Title
Mailing Address City State ZIP Code
E-mail Address Toll-free Phone # FAX #
INSTALLMENT PAYMENT INFORMATION
1. Enter your INSURANCE PREMIUM TAX LIABILITY from the ANNUAL TAX AND FEES 1.
REPORT for the period ended December 31st of the previous year (SECTION C, Line C10): $0.00
If Line 1 is at least $2,000, you must pay six installments during Calendar Year _____. 2.
Each installment must equal 15% of the amount on Line 1. $0.00
3. Check the box(es) pertaining to the installment(s) you are paying with this Report:
Installment 1, due March 15 Installment 3, due May 15 Installment 5, due July 15
Installment 2, due April 15 Installment 4, due June 15 Installment 6, due August 15
4. Installment payment amount: Line 2 times the number of boxes checked in Line 3. 4. $0.00
5. Penalty and interest calculation. If you file your installment late (using OPTins or by mail), you must pay a penalty
and interest. The penalty is 5% of the late-paid amount. Interest is 1% of the late-paid amount per full/partial month.
a. Date you will be filing your installment payment (either the 5a.
OPTins filing date or mail postmark date)
b. Based on the date on Line 5a, the penalty you must pay is: 5b. $0.00
c. Based on the date on Line 5a, the interest you must pay is: 5c. $0.00
6. TOTAL AMOUNT DUE: Line 4 + Line 5b + Line 5c 6. $0.00
FILING AND PAYMENT INSTRUCTIONS:
You must submit your filing and payment of the TOTAL AMOUNT DUE through OPTins or the mail on or before
the date you enter on Line 5a.
OPTION 1: Use the NAIC “OPTins” system to pay the amount due. Contact the OPTins Help Desk at firstname.lastname@example.org
or (816) 783-8990 to set up an OPTins account or for assistance with OPTins.
OPTION 2: Mail your Report and payment (made to ARIZONA INSURANCE TAX UNIT). See address at top.
DEPARTMENT OF INSURANCE ACCOUNTING INFORMATION
NAIC Period Tran Type Pay Code Installment Amount: Pay Code Penalty/Interest Amount
1 1 19 26
2 1 20 26
3 1 21 26
4 1 22 26
5 1 23 26
6 1 24 26
RECEIVED DATE (Stamp) Actual Postmark Date
(if received after due date)
Page 1 of 1 Installment Payment Report Form E-INSTALL