INDUSTRIAL COMMISSION OF ARIZONA INSURANCE CARRIERS 2008 TAX YEAR REPORT OF ANNUAL WORKERS’ COMPENSATION ADMINISTRATIVE FUND AND SPECIAL FUND PREMIUM TAX FORM 101 2008 NAIC #: FROM: Carrier Name DATE PREPARED: Address City State Zip Code Line 1 Workers’ compensation premiums collected (fill in the bolded cells) or contracted for during the year ended December 31, 2008. Line 1 $ Line 2 Amount of deductions from premiums: applicable cancellations, returned premiums, and all policy dividends or refunds paid or credited to policy holders within this State and not reapplied as premiums for new, additional or extended insurance. Line 3 Net taxable premiums (subtract line 2 from line 1): Line 4 Administrative Fund tax-A.R.S. § 23-961 (J) (multiply line 3 by 3.00%) Line 5 Total of quarterly payments made for 2008: Line 2 $ Line 3 $ Line 4 $ Line 5 $ LINE 6 Total Administrative Fund Premium tax due by March 1, 2009 (subtract line 5 from line 4): Line 6 $ LINE 7 Special Fund tax-A.R.S. § 23-1065 (A) (multiply line 3 by 1.50%) Line 7 $ LINE 8 Total of quarterly payments made for 2008: Line 8 $ LINE 9 Total Special Fund Premium tax due by March 1, 2009 (subtract line 8 from line 7): Line 9 $ IF TAX IS DUE FOR BOTH TAXES. (add line 6 and line 9) DO NOT SUBTRACT REFUND FROM TAX DUE Total Annual Tax due by March 1, 2008: TOTAL Direct Losses Paid in 2008: Please return completed form with a copy of “STATUTORY PAGE 14 - 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 Attention: Tax Accountant 800 West Washington Street, Room 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 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 per cent per month from the date the tax is due. A.R.S. § 23-961(N). TAX PAYMENTS ARE DUE MARCH 1, 2009. 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(M). I certify that the foregoing is correct to the best of my knowledge and belief. Officer Signature: Primary Email Address: Officer Name: Alternative Email Address: Officer Title: FAX Number: Date of Officer Signature: Primary Phone Number: Name and Title of Person completing form if different than above: Alternative Phone Number: Date Form Completed: American LegalNet, Inc. www.FormsWorkflow.com