Fill and Sign the Taxes Compensation Form

FROM:            DATE PREPARED:             $             $       $             $       Name:       Title:       Date:       this                         Telephone:             INDUSTRIAL COMMISSION OF ARIZONA REPORT OF ANNUAL WORKERS' COMPENSATION PREMIUM TAXES Carrier Name Addres s ADMINISTRATIVE FUND 1. Workers' compensation premiums collected or contracted for during the year ended December 31, 1999. 2. Less following 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 premiums for new, additional, or extended insurance. $( ) 3. Net taxable premiums (1 -2): 4. Administrative Fund tax-A.R.S. 23-961 (G) (multiply Line 3 by 3.00%): 5. Less quarterly payments made for 1999: $( ) 6. Total tax due by March 1, 2000: Please return completed form with a copy of ''PAGE 15 - EXHIBIT OF PREMIUMS AND LOSSES OF THE ANNUAL REPORT'' as filed with the Arizona Dept. of Insurance, with your check, payable to the Industrial Commission of Arizona, and mail to: Industrial Commission of Arizona 800 West Washington Street, Suite 301 Phoenix, Arizona 85007 Attention: Tax Accountant If there are any questions, please contact the Tax Accountant at 1-800-842-4681 (relay) request 602-542-7082 or e-mail at mailto:kmoriarty@ica.state.az.us. There is a penalty 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 are due. (A.R.S.23-961(J). THE REPORT IS DUE MARCH 1, 2000. The Industrial Commission will automatically return quarterly tax overpayments in excess of actual amount due. Overpayments cannot be applied against taxes due in the succeeding calendar year (A.R. S. 23-961 (I). I certify that the foregoing is correct to the best of my knowledge and belief. Signature : Subscribed and sworn to before me day of Notary Public Date Notary Expires (OVER ) ANNUAL WORKERS' COMPENSATION PREMIUM TAX REPORT INFORMATION If ''quarterly tax payments for year'' on Line 5 exceed the Administrative Fund Tax (Line 4), the overpayment will be refunded. Overpayments will not be credited against future quarterly taxes. Attach to the report a certified copy of PAGE 15 of your ''Annual Statement, Exhibit of Premiums and Losses.'' The report and check for taxes due must be received by the Industrial Commission on or before MARCH 1. (A.R.S. 23-961 (G). There is a penalty for failing to pay taxes 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. (A.R.S. 23-961 (J). Workers' Compensation insurers who were required to pay an Administrative Fund Tax of at least ''Quarterly Workers' Compensation Premium $2000 for the preceding calendar year must file a Taxes'' report and pay the taxes calculated for the current calendar year. The quarterly payments shall be due and payable on or before the last of the month following the close of the quarter (A.R.S. 23-961 (H).