Form MO375-0110 "Insurance Producers Report" - Missouri

What Is Form MO375-0110?

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

Form Details:

  • Released on November 1, 2019;
  • The latest edition provided by the Missouri Department of Commerce 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 MO375-0110 by clicking the link below or browse more documents and templates provided by the Missouri Department of Commerce and Insurance.

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Download Form MO375-0110 "Insurance Producers Report" - Missouri

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DUE FEBRUARY 10, 2020
MISSOURI DEPARTMENT OF COMMERCE AND
MISSOURI DEPARTMENT OF COMMERCE AND INSURANCE
INSURANCE
INSURANCE PRODUCERS REPORT
ATTN: PREMIUM TAX SECTION
P.O. BOX 690
JEFFERSON CITY, MISSOURI 65102-0690
INSTRUCTIONS
Pursuant to section 375.022, RSMo, an insurer authorized to transact the business of insurance in Missouri shall maintain a
register of appointed insurance producers who are authorized to sell, solicit or negotiate contracts of insurance on behalf of the
insurer. Regulation 20 CSR 200-3.300 states that on or before February 10th of each year, each foreign insurer authorized to
transact the business of insurance in Missouri shall file the following information with the Missouri Department of Commerce
and Insurance. Complete this form and return it to the above address, or email to us at premiumtax@insurance.mo.gov by
February 10, 2020. Questions may be directed to the above address, or you may contact us at (573) 526-4986 or (573) 751-
1929.
COMPANY NAME
DATE
NAIC #
STATE OF DOMICILE
CONTACT PERSON
PHONE NUMBER
E-MAIL ADDRESS
The following information must be included on the 2019 Missouri Premium Tax Return. Line 1 should agree with the ending number
of Producers Licensed in MO as of 12/31/2018 that was reported on Line 4 of your 2018 Insurance Producers Report Form.
1.) Number of insurance producers licensed in MO as of January 1, 2019
(Should match line 4 from previous year’s form)
2.) Number of insurance producers appointed in MO during 2019
3.) Number of insurance producers terminated in MO during 2019
4.) Number of insurance producers licensed in MO as of December 31, 2019
(Line 1, plus Line 2, minus Line 3)
5.) Number of Insurance Producer Renewals in MO during 2019 (Line 4 minus Line 2)
ONLY COMPLETE THE TABLE BELOW IF YOUR STATE OF DOMICILE HAS SEPARATE RATES FOR RESIDENT AND NON-RESI-
DENT APPOINTMENTS, TERMINATIONS OR RENEWALS.
NUMBER OF MO
NUMBER OF MO
MO PRODUCERS
NON-RESIDENT
TOTAL MO PRODUCERS
RESIDENT PRODUCERS
PRODUCERS
2019 APPOINTMENTS
2019 TERMINATIONS
2019 RENEWALS
MO 375-0110 (11-19)
Save
Print
Reset
DUE FEBRUARY 10, 2020
MISSOURI DEPARTMENT OF COMMERCE AND
MISSOURI DEPARTMENT OF COMMERCE AND INSURANCE
INSURANCE
INSURANCE PRODUCERS REPORT
ATTN: PREMIUM TAX SECTION
P.O. BOX 690
JEFFERSON CITY, MISSOURI 65102-0690
INSTRUCTIONS
Pursuant to section 375.022, RSMo, an insurer authorized to transact the business of insurance in Missouri shall maintain a
register of appointed insurance producers who are authorized to sell, solicit or negotiate contracts of insurance on behalf of the
insurer. Regulation 20 CSR 200-3.300 states that on or before February 10th of each year, each foreign insurer authorized to
transact the business of insurance in Missouri shall file the following information with the Missouri Department of Commerce
and Insurance. Complete this form and return it to the above address, or email to us at premiumtax@insurance.mo.gov by
February 10, 2020. Questions may be directed to the above address, or you may contact us at (573) 526-4986 or (573) 751-
1929.
COMPANY NAME
DATE
NAIC #
STATE OF DOMICILE
CONTACT PERSON
PHONE NUMBER
E-MAIL ADDRESS
The following information must be included on the 2019 Missouri Premium Tax Return. Line 1 should agree with the ending number
of Producers Licensed in MO as of 12/31/2018 that was reported on Line 4 of your 2018 Insurance Producers Report Form.
1.) Number of insurance producers licensed in MO as of January 1, 2019
(Should match line 4 from previous year’s form)
2.) Number of insurance producers appointed in MO during 2019
3.) Number of insurance producers terminated in MO during 2019
4.) Number of insurance producers licensed in MO as of December 31, 2019
(Line 1, plus Line 2, minus Line 3)
5.) Number of Insurance Producer Renewals in MO during 2019 (Line 4 minus Line 2)
ONLY COMPLETE THE TABLE BELOW IF YOUR STATE OF DOMICILE HAS SEPARATE RATES FOR RESIDENT AND NON-RESI-
DENT APPOINTMENTS, TERMINATIONS OR RENEWALS.
NUMBER OF MO
NUMBER OF MO
MO PRODUCERS
NON-RESIDENT
TOTAL MO PRODUCERS
RESIDENT PRODUCERS
PRODUCERS
2019 APPOINTMENTS
2019 TERMINATIONS
2019 RENEWALS
MO 375-0110 (11-19)