Fill - Free fillable INSTRUCTIONS FOR FORM E-II (Arizona) PDF form

Page 1 of 5 Industrial Insureds Premium Receipts Report

Form E-II (v20200131)

Insurance Tax Section Arizona

Department of Insurance

100 North 15th Avenue, Suite 261

Phoenix, AZ 85007-2630

Phone: (602) 364-3246

Web: https://insurance.az.gov

INDUSTRIAL INSURED PREMIUM

RECEIPTS TAX REPORT

(ARS § 20-401.07)

INSTRUCTIONS FOR FORM E-II

WHO MUST FILE FORM E-II?

This report must include each insurance policy you procured from an unauthorized insurer for

which Arizona is your "home state." Arizona is your home state when any of the following

three situations applies:

1. Your principal place of business is in Arizona AND at least some of the property or risk

covered by the insurance you procured is located in Arizona.

2. Your principal place of business is outside Arizona AND none of the property or risk

covered by the insurance you procured is located in the state where your principal place

of business is located AND Arizona is where the greatest percentage of your taxable

premium is allocated for the insurance contact.

3. You are reporting on behalf of an affiliated group of insureds named on a single

insurance contract procured from an unauthorized insurer and the member of the

affiliated group with the largest percentage of premium attributed to it under the

insurance contract has its principal place of business in Arizona.

If none of the foregoing situations apply to any of the insurance policies you procured,

do not file a report or pay a tax to Arizona.

HOW IS THE TAX CALCULATED?

For each insurance policy for which Arizona is your home state, you must pay the 3% tax on

ALL (100%) of the premium, regardless of the portion of the premium that applies to risk or

property within Arizona. For informational purposes only, Form E-II asks you to report the

percentage of premium allocable to property/risk located in Arizona.

WHERE DO I SEND MY COMPLETED REPORT AND TAX PAYMENT?

INSURANCE TAX SECTION

Arizona Department of Insurance

100 N 15th Ave. # 261

Phoenix, AZ 85007-2630

WHEN IS THE COMPLETED REPORT AND TAX PAYMENT DUE?

 August 15 for all transactions effective January 1 through June 30

 February 15 for all transactions effective July 1 through December 31

When submitting your tax report, please do not submit this instruction page.

Page 2 of 5 Industrial Insureds Premium Receipts Report

Form E-II (v20200131)

Insurance Tax Section

Arizona Department of Insurance

100 North 15th Avenue, Suite 261

Phoenix, AZ 85007-2630

Phone: (602) 364-3246

Web: https://insurance.az.gov

INDUSTRIAL INSURED

PREMIUM RECEIPTS TAX

REPORT (ARS § 20-401.07)

for the period of

Original Filing Amended Filing

FILE SEMIANNUALLY ►by 8/15 for 1/1-6/30 premiums, and ►by 2/15 for 7/1-12/31 premiums.

SECTION A: CONTACT INFORMATION

TAX UNIT:II#-

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- TransType-

B1 Sum of PREMIUM AMOUNTS from Section E, Box E9a

B2 Tax due = Line B1 X 3%. Make payment out to AZ Dept of Insurance.

Ø8

B3 Sum of [premium amount times "% in AZ"] from Section E, Box E9c

(for Tax Unit use only - not used to calculate tax)

SECTION C: INDUSTRIAL INSURED QUALIFICATIONS. Answers to the following questions determine if you

meet qualifications to be an industrial insured. New qualifications became effective January 1, 2015. If you do

not meet the new 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.

C1 During the most recently ended fiscal year, did the insured apply for or

procure property and/or casualty insurance to cover risks or operations in

Arizona other than for risks excluded by ARS § 20-382 with annual gross

premiums totaling at least $100,000?

Yes No

As of the end of the most recent fiscal y

ear, did the insured possess a net

worth of at least $22,040,000* as verified by a certified public accountant?

Yes No

C3 During the most recently ended fiscal year, did the insured have net

revenues or sales exceeding $50,000,000 as verified by a CPA?

Yes No

C4 Does the insured have more than 500 full-time employees or equivalent? Yes No

C5 Is the insured a member of an affiliated group employing more than 1,000

full-time employees in the aggregate?

Yes No

C6 Is the insured a municipality with a population of over 50,000 persons? Yes No

Is the insured a nonprofit organization or public entity with annual budgeted

expenditures of at least $33,060,000*?

Yes No

If you answered "No" to C1, or if you answered "No" to all questions in C2 through C7, you do not qualify as an

industrial insured. File this report but cease procuring insurance directly from non-admitted insurers.

_______________________________

*NOTE: The amounts in lines C2 and C7 will change effective January 1, 2020 (for reports due from and after

August 2020) by the change to the consumer price index for all urban consumers published by the US

Department of Labor Bureau of Labor Statistics. The report filed for the July 1 through December 31, 2019

semi-annual period is the last report that can be filed using this version of this form.

7/1 - 12/31

2019

✔

$0.00

Page 3 of 5 Industrial Insureds Premium Receipts Report

Form E-II (v20200131)

Complete Name of Insured

SECTION D: QUALIFIED RISK MANAGER. Indicate which of the following federal and state qualifications

your risk manager satisfies. If "None," you must cease procuring insurance directly from non-admitted insurers.

10 years of relevant experience (Line D10). None.

7 years of relevant experience (Line D10) AND at least one relevant professional designation (Lines

D5 - D9).

A bachelor's degree from an accredited college/university in risk management, business

administration, finance, economics or another field determined by the director of insurance to

demonstrate competence in risk management AND EITHER:

 3 years of relevant experience (Line D10) OR

 At least one relevant professional designation (Lines D5 - D9).

A graduate degree from an accredited college/university in risk management, business administration,

finance, economics or another field determined by the director of insurance to demonstrate

competence in risk management (Line D4).

D1 - Last Name First Name Middle Name Jr./Sr./II/III/etc.

D2 Relationship of qualified risk manager to the insured

Employee Third-party consultant

D3 Major/field for bachelor's degree: College/university: Graduation mo/yr

D4 Major/field for graduate degree: College/university: Graduation mo/yr

D5 Does the risk manager hold a designation as a Chartered Property and Casualty

Underwriter issued by the American Institute for CPCU/Insurance Institute of

America?

Yes No

D6 Does the risk manager hold a designation as an Associate in Risk Management

issued by the American Institute for CPCU/Insurance Institute of America?

Yes No

D7 Does the risk manager hold a designation as Certified Risk Manager issued by

the National Alliance for Insurance Education & Research?

Yes No

D8 Does the risk manager hold a designation as a RIMS Fellow issued by the Global

Risk Management Institute?

Yes No

D9 Does the risk manager hold any other designation, certification or license that

shows the risk manager possesses competency to act as the insured's risk

manager? If "Yes," describe below:

_________________________________________________________________

Yes No

D10 In this section, report the risk manager's relevant experience during the past 10 years. For each job,

use the "Code" column to identify whether the experience involved [A] risk financing, [B] claims

administration, [C] loss prevention, [D] risk and insurance coverage analysis, or [E] purchasing

commercial lines of insurance. Provide additional signed and dated sheets if necessary.

Code Name of Employer Job Title Start (mm/yy) End (mm/yy)

Page 4 of 5 Industrial Insureds Premium Receipts Report Form E-II (v20200131)

Complete Name of Insured

SECTION E: INSURANCE PROCURED FROM NON-ADMITTED INSURERS. When Arizona is the "home

state," you must pay tax on all premiums (regardless of the portion allocable to risks or property in Arizona) for

insurance you procure from non-admitted insurers. Post information from E1 through E8 into E9.

Arizona is the home state for a insurance policy when ANY of the following three circumstances applies:

1. The insured's principal place of business is in Arizona and at least some of the property or risk

covered by the insurance is located in Arizona.

2. The insured's principal place of business is outside Arizona and both,

a. None of the property or risk covered by the insurance is located in the state where the

insured's principal place of business is located AND

b. Arizona is where the greatest percentage of the insured's taxable premium is allocated for the

insurance contract.

3. More than one insured from an affiliated group are named insureds on a single non-admitted

insurance contract and the member of the affiliated group with the largest percentage of premium

attributed to it under the insurance contract has its principal place of business in Arizona.

DO NOT SUBMIT THIS INDUSTRIAL INSUREDS PREMIUM TAX REPORT (FORM E-II) IF YOU DID NOT

PROCURE INSURANCE FOR WHICH ARIZONA IS THE HOME STATE.

Policy Number Coverage Start Date Coverage Expiration Date Premium Due/Paid

Full Name of Non-admitted Insurer or Lloyd's Broker/Syndicate PREMIUM AMOUNT

Insurer's or Lloyd's Broker Address City State Country ZIP Code

Type of Insurance Property/Risk Covered by the Insurance % of property/risk w/in AZ