"Signature Page" - Nebraska

Signature Page is a legal document that was released by the Nebraska Department of Insurance - a government authority operating within Nebraska.

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Download "Signature Page" - Nebraska

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SIGNATURE PAGE
STATE OF NEBRASKA
DEPARTMENT OF INSURANCE
ANNUAL TAX RETURN FOR YEAR ENDING DECEMBER 31, 2019
This document must be attached to all annual tax return filings.
COMPANY INFORMATION
Contact Person
NAIC Number
E-Mail Address
Federal Tax I.D. Number
Telephone
Company Name
Street Address
City
State
Zip Code
Organized Under the Laws of
TYPE OF INSURER (Select One):
Life and Health Insurer
Pool
Property and Casualty Company
Assessment
Reciprocal Insurance Exchange
Prepaid Dental
Risk Retention Group
Prepaid Legal
Title Insurer
Prepaid Health
Health Maintenance Organization
Captive
Fraternal
SIGNATURE OF FISCAL OFFICER OF COMPANY
State of
)
)ss
County of
)
,
I,
being duly sworn on oath say that I am
of the
Insurance Company of the State of
and that the tax statement to which this is attached is correctly computed in accordance with the provided instructions.
(Signature)
Subscribed and sworn to before me, a Notary Public, this
day of
20
(Notary Public)
Page 1 of 1
NE Signature Page V1
SIGNATURE PAGE
STATE OF NEBRASKA
DEPARTMENT OF INSURANCE
ANNUAL TAX RETURN FOR YEAR ENDING DECEMBER 31, 2019
This document must be attached to all annual tax return filings.
COMPANY INFORMATION
Contact Person
NAIC Number
E-Mail Address
Federal Tax I.D. Number
Telephone
Company Name
Street Address
City
State
Zip Code
Organized Under the Laws of
TYPE OF INSURER (Select One):
Life and Health Insurer
Pool
Property and Casualty Company
Assessment
Reciprocal Insurance Exchange
Prepaid Dental
Risk Retention Group
Prepaid Legal
Title Insurer
Prepaid Health
Health Maintenance Organization
Captive
Fraternal
SIGNATURE OF FISCAL OFFICER OF COMPANY
State of
)
)ss
County of
)
,
I,
being duly sworn on oath say that I am
of the
Insurance Company of the State of
and that the tax statement to which this is attached is correctly computed in accordance with the provided instructions.
(Signature)
Subscribed and sworn to before me, a Notary Public, this
day of
20
(Notary Public)
Page 1 of 1
NE Signature Page V1