INDUSTRIAL COMMISSION OF ARIZONA INSURANCE CARRIER QUARTERLY ADMINISTRATIVE AND SPECIAL FUND TAX FORMS #101 C FOR 2009 FROM: March 31, 2009 DUE April 30, 2009 June 30, 2009 DUE July 31, 2009 September 30, 2009 DUE October 31, 2009 December 31, 2009 DUE January 31, 2010 Carrier Name Street Address City State Zip code 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: ADMINISTRATIVE FUND A.R.S. § 23-961 (K) 1 2008 Net Taxable Premium from line 3 of Form 101 Line A1 $ 2 Administrative tax - A.R.S. § 23-961 (K) (Multiply Line 1 by 3.0%) Line A2 $ 3 Multiply Line 2 by 25.0% or 0.25 Line A3 $ 4 Special Fund - A.R.S. § 23-1065 (A) (Multiply line 1 by 1.50%) Line A4 $ 5 Multiply Line 2 by 25.0% or 0.25 Line A5 $ 6 Amount Paid (Add lines A3 & A5 together and pay this amount) Line A6 $ B. Method II : 1 Total of all premiums collected or contracted for during quarter ended__________: Line B1 $ 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_________. Line B2 $ 3 Net taxable premiums (Subtract Line B2 from Line B1) Line B3 $ 4 Administrative Fund tax ( Multiply Line B3 by 3.0%) Line B4 $ 5 Special Fund tax (Multiply Line B3 by 1.5%) 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 taxes@ica.state.az.us 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:_____________________________________________ American LegalNet, Inc. www.FormsWorkflow.com