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INSURANCE TAX UNIT INSTALLMENT PAYMENT REPORT For installments

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INSURANCE TAX UNIT INSTALLMENT PAYMENT REPORT For installments Powered By Docstoc
					                                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
                                                                                       Reset
                                                                                                                  2011
                                                                                               CALENDAR YEAR _______
                                 http://www.azinsurance.gov
INFORMATION ABOUT THE INSURER
Name of Insurer                                                                                      NAIC #           Domicile* State
                                                                                                        12121
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
2.                                                                                       2011
       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 optinshelp@naic.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

				
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posted:8/8/2011
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