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Annual Report And Renewal For Fraternal Companies - South Dakota Division Of Insurance - 2011

SOUTH DAKOTA DIVISION OF INSURANCE

445 EAST CAPITOL AVENUE

PIERRE, SD 57501

605-773-3563

2011 ANNUAL REPORT AND RENEWAL

FOR FRATERNAL COMPANIES

DUE BY MARCH 1, 2012

: ____________________________________________________________

FRATERNAL SOCIETY

: ______________________________________________________________________

ADDRESS

STREET

CITY

STATE

ZIP

# ____________

DOMICILE: ________ P

: ___________________________

NAIC

RESIDENT

: ____________________

CONTACT NAME: __________________________________

PHONE

INSTRUCTIONS:

PURSUANT TO SDCL 58-37A-26 AND 58-37A-27, ONE OF TWO

FRATERNAL PREMIUM CLASSIFICATIONS APPLY. PLEASE CHECK THE APPLICABLE

CLASSIFICATION AND RETURN THIS FORM ALONG WITH CORRECT PAYMENT TO THE

ADDRESS LISTED ABOVE. MAKE CHECK PAYABLE TO: SD DIVISION OF INSURANCE

________ PREMIUM VOLUME OF $200,000 OR MORE:

$ 500 RENEWAL FEE

$ 500 ANNUAL STATEMENT FILING FEE

$ 1,000 ANNUAL EXAMINATION ASSESSMENT FEE.

$2,000 TOTAL DUE

________ PREMIUM VOLUME LESS THAN $200,000:

$ 100 RENEWAL FEE

$ 100 ANNUAL STATEMENT FILING FEE

$ 1,000 ANNUAL EXAMINATION ASSESSMENT FEE

$ 1,200 TOTAL DUE

Annual Report And Renewal For Fraternal Companies - South Dakota Division Of Insurance - 2011