Premium Tax Report Surplus Lines Broker Form - South Dakota Division Of Insurance printable pdf download

Premium Tax Report Surplus Lines Broker Form - South Dakota Division Of Insurance

SOUTH DAKOTA DIVISION OF INSURANCE

445 East Capitol Avenue, 1st Floor

Pierre, South Dakota 57501

Main Line (605) 773-3563 Fax: (605) 773-5369

PREMIUM TAX REPORT

SURPLUS LINES BROKER

REPORT OF PREMIUMS COLLECTED AS OF DECEMBER 31, ____________.

DATE DUE: BEFORE APRIL 1

NAME:_____________________________________________________________________________

BUSINESS NAME:___________________________________________________________________

BUSINESS ADDRESS:________________________________________________________________

License Number: __________________________ BUS. PHONE:______________________________

PART I. SURPLUS LINES PREMIUM COLLECTED:

List all Insurance Companies and the premium collected for each company. Attach additional pages if necessary. Also

include the name & address of the insured, effective date & amount of premium written for each policy.

PREMIUM

NAME

ADDRESS

COLLECTED

___________

TOTAL PREMIUM WRITTEN $__________

=========

*This amount must equal PART II line 3.

PART II. PREMIUM COLLECTED REPORT:

Total Fire premium collected

(1) $______________________________

Total Other premium collected

(2) $______________________________

Add: (1) + (2) Total Premium Collected

(3) $______________________________

PART III. PREMIUM TAX CALCULATION:

Multiply Line (1) x SD Fire Premium Tax Rate: 3% =

(4) $______________________

Multiply Line (2) x SD All Other Premium Tax Rate: 2.5% = (5) $______________________

________________________

Add: (4) +(5): Total Premium Tax =

(6) $______________________

======================

Premium Tax Report Surplus Lines Broker Form - South Dakota Division Of Insurance