Sd Eform-1427 V1 - Self Procured Insurance And Premium Tax Report - South Dakota Division Of Insurance

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SD EForm - 1427
V1
HELP
Complete and use the button at the end to print for mailing.
SOUTH DAKOTA DIVISION OF INSURANCE
445 EAST CAPITOL AVENUE, 1ST FLOOR
PIERRE, SD 57501
(605) 773-3563
SELF-PROCURED INSURANCE & PREMIUM TAX REPORT
Date Due: Within 30 days of procurement
NAME OF INDIVIDUAL OR BUSINESS:
________________________________________
ADDRESS:
________________________________________
________________________________________
________________________________________
________________________________________
________________________________________
DAYTIME PHONE NUMBER:____________________________
CONTACT PERSON:
________________________________
List Insurance Company Name and Address where Insurance was placed and the Total Amount of Coverage
applicable to South Dakota Risk.
TOTAL AMOUNT
NAME
ADDRESS
PROCURED
1.
2.
3.
______________
TOTAL PREMIUMS
$
0.00
=============
PREMIUM TAX CALCULATION:
Multiply TOTAL PREMIUMS x SD Fire Premium Tax Rate: 3% =
$___________________
TOTAL PREMIUMS x SD All Other Premium Tax Rate: 2.5% =
$___________________
_____________________
0.00
Total Premium Tax =
$___________________
====================
____________________________________________
____________________________
(SIGNATURE)
(EFFECTIVE DATE)
1.
PRINT FOR MAILING
EXIT
CLEAR FORM
2.

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