Form RRG "Annual Report of Premiums Paid to Risk Retention Groups" - New Jersey

What Is Form RRG?

This is a legal form that was released by the New Jersey Department of Banking and Insurance - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2009;
  • The latest edition provided by the New Jersey Department of Banking and Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form RRG by clicking the link below or browse more documents and templates provided by the New Jersey Department of Banking and Insurance.

ADVERTISEMENT
ADVERTISEMENT

Download Form RRG "Annual Report of Premiums Paid to Risk Retention Groups" - New Jersey

Download PDF

Fill PDF online

Rate (4.7 / 5) 63 votes
STATE OF NEW JERSEY
RRG
(11-09)
ANNUAL REPORT OF PREMIUMS PAID TO RISK RETENTION GROUPS
NOT CHARTERED IN NEW JERSEY FOR COVERAGE ON RISKS WITHIN NEW JERSEY
For Calendar Year Ended December 31, _________
Place the label provided below. Make necessary corrections on the label. Otherwise,
Federal Identification Number
type or print the requested information.
Check if address change appears below.
Name of Risk Retention Group
NAIC Number
Mailing Address
Party to contact regarding this return
City
State
ZIP Code
Title
Phone Number
(
)
Business Address if Different from Mailing Address
City
State
ZIP Code
State(s) in which Chartered or Licensed as a Liability Insurance Company
IMPORTANT: ALL TAXPAYERS MUST FOLLOW THE INSTRUCTIONS BELOW.
State of New Jersey
Division of Taxation
The original return, along with payment for the amount indicated on line 5
PO Box 247
below, payable to the State of New Jersey - RRG, must be filed with the
Trenton, NJ 08695-0247
Director, Division of Taxation, postmarked on or before March 1 annually, and
sent to the address indicated at the right.
AND ALSO
State of New Jersey
Department of Banking and Insurance
A duplicate copy of this return must also be filed with the Commissioner of
Div. of Financial Examinations - Tax Unit
Banking and Insurance, on or before March 1 annually, and sent to the
PO Box 325
address indicated at the right.
Trenton, NJ 08625-0325
The above Risk Retention Group does hereby submit the following report for the calendar year ending December 31, ______________ as
required by and in accordance with Chapter 240, Laws of 1993, approved August 9, 1993 (N.J.S.A. 17:47A-5c. and d.)
TAX COMPUTATION
1. TOTAL PREMIUMS RECEIVED FOR COVERAGE ON RISKS
LOCATED IN NEW JERSEY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________________________
2. DEDUCTIONS:
a.
Premiums Returned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________________________
b.
Dividends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________________________
c.
Total Deductions (Line 2(a) Plus Line 2(b)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________________________
3. TAXABLE PREMIUMS (Line 1 minus Line 2(c)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________________________
4. TAX RATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___________5%__________
5. TAX (Line 3 times .05) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
________________________
SIGNATURE
VERIFICATION
AND
The above statement is a true and correct report of premiums paid to the above Risk Retention Group for coverage on risks within New Jersey during the
calendar year indicated above.
___________________________________________________________________________________________________________________________
(Date)
(Signature of Duly Authorized Officer of Taxpayer)
(Title)
___________________________________________________________________________________________________________________________
(Date)
(Signature of Individual Preparing Return)
(Preparer’s ID No.)
___________________________________________________________________________________________________________________________
(Name of Tax Preparer’s Employer)
(Employer’s ID No.)
STATE OF NEW JERSEY
RRG
(11-09)
ANNUAL REPORT OF PREMIUMS PAID TO RISK RETENTION GROUPS
NOT CHARTERED IN NEW JERSEY FOR COVERAGE ON RISKS WITHIN NEW JERSEY
For Calendar Year Ended December 31, _________
Place the label provided below. Make necessary corrections on the label. Otherwise,
Federal Identification Number
type or print the requested information.
Check if address change appears below.
Name of Risk Retention Group
NAIC Number
Mailing Address
Party to contact regarding this return
City
State
ZIP Code
Title
Phone Number
(
)
Business Address if Different from Mailing Address
City
State
ZIP Code
State(s) in which Chartered or Licensed as a Liability Insurance Company
IMPORTANT: ALL TAXPAYERS MUST FOLLOW THE INSTRUCTIONS BELOW.
State of New Jersey
Division of Taxation
The original return, along with payment for the amount indicated on line 5
PO Box 247
below, payable to the State of New Jersey - RRG, must be filed with the
Trenton, NJ 08695-0247
Director, Division of Taxation, postmarked on or before March 1 annually, and
sent to the address indicated at the right.
AND ALSO
State of New Jersey
Department of Banking and Insurance
A duplicate copy of this return must also be filed with the Commissioner of
Div. of Financial Examinations - Tax Unit
Banking and Insurance, on or before March 1 annually, and sent to the
PO Box 325
address indicated at the right.
Trenton, NJ 08625-0325
The above Risk Retention Group does hereby submit the following report for the calendar year ending December 31, ______________ as
required by and in accordance with Chapter 240, Laws of 1993, approved August 9, 1993 (N.J.S.A. 17:47A-5c. and d.)
TAX COMPUTATION
1. TOTAL PREMIUMS RECEIVED FOR COVERAGE ON RISKS
LOCATED IN NEW JERSEY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________________________
2. DEDUCTIONS:
a.
Premiums Returned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________________________
b.
Dividends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________________________
c.
Total Deductions (Line 2(a) Plus Line 2(b)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________________________
3. TAXABLE PREMIUMS (Line 1 minus Line 2(c)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________________________
4. TAX RATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___________5%__________
5. TAX (Line 3 times .05) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
________________________
SIGNATURE
VERIFICATION
AND
The above statement is a true and correct report of premiums paid to the above Risk Retention Group for coverage on risks within New Jersey during the
calendar year indicated above.
___________________________________________________________________________________________________________________________
(Date)
(Signature of Duly Authorized Officer of Taxpayer)
(Title)
___________________________________________________________________________________________________________________________
(Date)
(Signature of Individual Preparing Return)
(Preparer’s ID No.)
___________________________________________________________________________________________________________________________
(Name of Tax Preparer’s Employer)
(Employer’s ID No.)