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Get Life Companies Including Accident And Health Insurance Tax Return

Er Fed Tax I.D. No. CA Perm No. EFT Taxpayer I.D. No. Method of Tax Payment Mailing Address City, State, Zip Telephone & Fax # State of Domicile If New Company, check here If Name Change, check here If Final Return, check here No Payment Check EFT If Amended Return, check here and indicate the effective date of the final transaction. and indicate the date when it was amended. STATEMENT OF TAXABLE PREMIUMS AND TAXES DUE DURING CALENDAR YEAR 2004 CDI use only A. Qualified B. Nonqualified.

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