Free Insurance Carrier ADM SPF Q.xls - Arizona

INDUSTRIAL COMMISSION OF ARIZONA INSURANCE CARRIER QUARTERLY ADMINISTRATIVE AND SPECIAL FUND TAX FORMS #101 C FOR 2009

FROM: Carrier Name

March 31, 2009 June 30, 2009 Street Address September 30, 2009 City State Zip code December 31, 2009

DUE DUE DUE DUE

April 30, 2009 July 31, 2009 October 31, 2009 January 31, 2010

NAIC #:

COMPUTATION OF QUARTERLY TAXES
Insurers who were required to pay an Administrative Fund tax of at least $2,000 for the preceding calendar year must file this report and pay the taxes calculated for the current calendar year. A.R.S. § 23-961 (L)

A. Method I:
1 2008 Net Taxable Premium from line 3 of Form 101 2 Administrative tax - A.R.S. § 23-961 (K) (Multiply Line 1 by 3.0%) 3 Multiply Line 2 by 25.0% or 0.25 4 Special Fund - A.R.S. § 23-1065 (A) (Multiply line 1 by 1.50%) 5 Multiply Line 2 by 25.0% or 0.25 6 Amount Paid (Add lines A3 & A5 together and pay this amount) Line A1 $ Line A2 $ Line A3 $ Line A4 $ Line A5 $ Line A6 $

ADMINISTRATIVE FUND A.R.S. § 23-961 (K)

B. Method II :
1 Total of all premiums collected or contracted for during quarter ended__________: 2 Amount of deductions from premiums: Applicable cancellations, returned premiums, and all policy dividends or refunds paid or credited to policyholders within this State and not reapplied as premium for new, additional or extended insurance for quarter ended_________. 3 Net taxable premiums (Subtract Line B2 from Line B1) 4 Administrative Fund tax ( Multiply Line B3 by 3.0%) 5 Special Fund tax (Multiply Line B3 by 1.5%) Line B1 $

Line B2 $ Line B3 $ Line B4 $ Line B5 $

Line B6 $ 6 Amount Paid (Add lines B4 & B5 together and pay this amount) Penalty and interest will be assessed for failing to pay the tax on time: The greater of twenty-five dollars or five percent of the tax due plus interest at the rate of one percent per month from the date the tax was due, which is 30 days after close of the quarter. A.R.S. § 23-961 (N) Please return the COMPLETED FORM with your check payable to Industrial Commission of Arizona for the total payment due and mail to: Industrial Commission of Arizona Attention: Tax Accountant 800 West Washington Street, Suite 301 Phoenix, Arizona 85007 If there are any questions, please contact the Tax Accountant at 602-542-1836 or e-mail at [email protected]
I certify that the foregoing is correct to the best of my knowledge and belief: (please complete all of the information

Officer Signature:__________________________________________________Primary Email Address: Name: Title: Alternative Email Address: FAX Number:

Date of Officer Signature:___________________________________________ Primary Phone Number: Name and Title of Person completing form if different than above: Alternative Phone Number: Alternative Phone Number: Name and Title of Person completing form (listed below): Date Form Completed:_____________________________________________