Form 74a110 - Kentucky Estimated Insurance Premiums Tax

74A110 (12-04)

KENTUCKY ESTIMATED

FOR OFFICIAL USE ONLY

Commonwealth of Kentucky

INSURANCE PREMIUMS TAX

DEPARTMENT OF REVENUE

3 2

0 6 0 5

__ __

__ __ __ __

For Calendar Year 2005

Tax

Period

Tr.

Account Number __ __ __ __ __

Due June 1, 2005

FEIN __ __ – __ __ __ __ __ __ __

NAIC/

TAX ID

FIRST INSTALLMENT

Check appropriate block:

Name of Company

Report based on previous year’s liability

Address

Number and Street

Report based on current year estimate

City, Town or Post Office

State

ZIP Code

A. Premiums tax on life and health policies .................................................... (01)

B. Premiums tax on other than life policies (excluding

workers’ compensation policies) ................................................................ (02)

C. Retaliatory taxes and fees on foreign and alien insurers ............................ (06)

D. Total installment due (total of lines A, B and C) .......................................

I, the undersigned, declare under the penalties of perjury, that I have examined these returns, including all accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct and complete.

Date

Signature of Officer or Agent

Title of Officer

Print or Type Name of Officer or Agent

Telephone Number

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