Form ECAB "Kansas Excess Lines Premium Tax Reporting Statement Form" - Kansas

What Is Form ECAB?

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

Form Details:

  • The latest edition provided by the Kansas Insurance Department;
  • 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 ECAB by clicking the link below or browse more documents and templates provided by the Kansas Insurance Department.

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Download Form ECAB "Kansas Excess Lines Premium Tax Reporting Statement Form" - Kansas

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ECAB FILING FORM
INSTRUCTIONS
Pursuant to K.S.A. 40-246c: Regarding reporting the placement of excess lines business placed on a risk
domiciled in a state other than Kansas, but also covering a risk or location in Kansas, any individual
placing a policy with an insurer not authorized to do business in this state shall file this form WITHIN 120
DAYS AFTER WRITING THE RISK.
Transaction Code A, C, E, N, R: Refer to the code on accompanying Coverage Type Form. Indicate the
type of transaction that is being reported, using the following code: A- audit, C- cancellation, E -
endorsement, N - new, R - renewal. If codes A, C, or E are used and had been reported on a previous
report, indicate the page or row number on which the listing can be found in Notes column.
Effective Date: Date policy was written.
Expiration Date: List policy's expiration date.
Policy Number: List policy's policy number, Numeric and Alpha characters only, no spaces or dashes.
Description & Kansas Location Of Risk: List Kansas location and description of risk insured.
Name& Address of Insured: Enter the named insured information from the policies declaration
page.
Coverage Type: Refer to the code on accompanying Coverage Type Form. Enter only the 3 digit number,
i.e.: for GL- type 270, for E & O, type 280, Terrorism type- 310
Insurer NAIC #:
For a listing of non-admitted surplus lines insurers, please access this link:
http://www.ksinsurance.org/company/eslines/main_report.pdf
or if you need to check if a specific company
is listed, on our website, simply click on “Find a Company” under Quick Links on the left hand side of our
home page,
www.ksinsurance.org
.
If various companies were used on any one risk, list each company
used and applicable premium attributable to each company, multiple rows can be used.
Gross Premium Charged: The gross premium is the total amount charged the insured before figuring the
6% premium tax. Gross premium would include any cost charged in the placement of the insurance
including, policy or inspection fees.
Premium Tax Due: Premium tax due is 6%.
Penalty Tax: If there is a policy that is being reported late, (after 120 days), there is a penalty due,
complete this column. Penalty is an additional 6%.
Notes: Use this column to list previously reported policy or any other information that you would deem
necessary.
Name of Placing Agent:
List the agent who signs the policy or the agent of record with the company.
Signature of Agent: Signature of agent who signs the policy or the agent of record with the company.
List the date this form is completed.
Date:
ECAB FILING FORM
INSTRUCTIONS
Pursuant to K.S.A. 40-246c: Regarding reporting the placement of excess lines business placed on a risk
domiciled in a state other than Kansas, but also covering a risk or location in Kansas, any individual
placing a policy with an insurer not authorized to do business in this state shall file this form WITHIN 120
DAYS AFTER WRITING THE RISK.
Transaction Code A, C, E, N, R: Refer to the code on accompanying Coverage Type Form. Indicate the
type of transaction that is being reported, using the following code: A- audit, C- cancellation, E -
endorsement, N - new, R - renewal. If codes A, C, or E are used and had been reported on a previous
report, indicate the page or row number on which the listing can be found in Notes column.
Effective Date: Date policy was written.
Expiration Date: List policy's expiration date.
Policy Number: List policy's policy number, Numeric and Alpha characters only, no spaces or dashes.
Description & Kansas Location Of Risk: List Kansas location and description of risk insured.
Name& Address of Insured: Enter the named insured information from the policies declaration
page.
Coverage Type: Refer to the code on accompanying Coverage Type Form. Enter only the 3 digit number,
i.e.: for GL- type 270, for E & O, type 280, Terrorism type- 310
Insurer NAIC #:
For a listing of non-admitted surplus lines insurers, please access this link:
http://www.ksinsurance.org/company/eslines/main_report.pdf
or if you need to check if a specific company
is listed, on our website, simply click on “Find a Company” under Quick Links on the left hand side of our
home page,
www.ksinsurance.org
.
If various companies were used on any one risk, list each company
used and applicable premium attributable to each company, multiple rows can be used.
Gross Premium Charged: The gross premium is the total amount charged the insured before figuring the
6% premium tax. Gross premium would include any cost charged in the placement of the insurance
including, policy or inspection fees.
Premium Tax Due: Premium tax due is 6%.
Penalty Tax: If there is a policy that is being reported late, (after 120 days), there is a penalty due,
complete this column. Penalty is an additional 6%.
Notes: Use this column to list previously reported policy or any other information that you would deem
necessary.
Name of Placing Agent:
List the agent who signs the policy or the agent of record with the company.
Signature of Agent: Signature of agent who signs the policy or the agent of record with the company.
List the date this form is completed.
Date:
: List reporting agent's agency name,
Name of Agency, Address, City, State, Zip, and Phone Number
address and agent’s phone number, or if someone other than reporting agent is completing this form,
list that person's number.
Provide reporting agent’s email address unless if someone other than licensed agent is
Email Address:
completing this form, list that person's email address.
As we are doing a large portion of our correspondence electronically, it is very important that we have your
correct contact information, especially your email address,
all deposits are coded to this number. Without this
Tax I.D. Number: List agency’s Federal Tax I.D. Number,
number any future refunds cannot be processed.
Statement of Insured: THIS FORM IS TO BE USED BY KANSAS RESIDENT NON EXCESS
LINES LICENSED AGENTS ONLY. NO OTHER AGENTS ARE REQUIRED TO SUBMIT THIS
FORM.
KANSAS RESIDENT NON EXCESS LINES LICENSED AGENTS ONLY: Prior to placing insurance
with an insurer not authorized to do business in this state, obtain the written consent of the prospective
named insured and provide such insured required information in a form promulgated by the commissioner,
(Form ECAD). A copy of this form is to be retained in insured’s file.
No additional forms are required to be submitted.
If you should have any questions, please do not hesitate in contacting this department.
Phone number: 785.296.7832 or Email: ptavares@ksinsurance.org. Addition forms can
be found at the Department’s web page at:
http://www.ksinsurance.org/agent/Out_of_State_Domiciled_Risks_Tax_Packet.pdf
Remember filing your Excess Line Taxes is as easy as 1, 2, 3!!!
1. Download Form ECAB
2. Complete Form ECAB
3. Mail in completed Form ECAB & check made out to: Kansas Ins. Dept. for any
E&S tax due
IMPORTANT: Form ECAB and Tax are
DUE & must be RECEIVED within 120
days of writing policy!
Kansas Excess Lines Premium Tax Reporting Statement Form ECAB
To Be Completed by Individuals Other than Kansas Licensed Excess Coverage Agents
Statutory Authorization
“...Any individual placing a policy with an insurer not authorized to do business in this state on a risk domiciled in a state other than this state, but also
(Excerpt from K.S.A. 40246c)
covering a risk or location in Kansas, shall file with the commissioner a statement in the form prescribed by the commissioner, describing the risk and
shall pay to the commissioner a sum equal to 6% of the portion of the premium applicable to the risk located in Kansas within 120 days after
writing the risk. The individual responsible for filing the statement shall be the agent who signs the policy or the agent of record with the company. The
commissioner...shall collect double the amount of tax herein provided from any...other responsible individual as herein described who shall fail, refuse or
neglect to transmit the required...statement or shall fail to pay the tax imposed by this section, to the commissioner within the period specified.”
This form must be completed for each policy issued or renewed as indicated above. Submit completed form(s) and payment of premium tax to:
Kansas Insurance Department, Fire & Casualty Division, 420 S.W. 9th Street, Topeka, Kansas 66612-1678
Gross
Premium
Penalty
Transaction
Effective
Expiration
Policy
Description & Kansas
Name & Address of Insured
Coverage
Insurer
Notes
Premium
Tax Due
Tax
Code
Date
Date
Number
Location of Risk
Type
NAIC #
Charged
(2)
(3)
(1)
Code
A,C,E,N,R
(1) Enter only the premium dollar amount that is the portion of the premium applicable to the risk located in Kansas.
(2) The Kansas Excess Lines Premium Tax rate is 6% if paid within 120 days after writing the risk.
(3) After 120 days the rate is 12%.
I hereby certify that I am the agent who signed the policy or the agent of record with the company writing the risk in compliance with the requirements of
K.S.A. 40-246(c), that under the penalty of perjury under the laws of the state of Kansas, I hereby make this report of business produced by me under said statute.
Name of Placing Agent
Signature of Placing Agent
Date Completed
Name of Agency
Address
City, State, Zip
Phone Number
E-Mail Address
Tax I.D. Number
ECAB Form v1.06
Recd: ____________________ AMT$ ____________________CK#____________________FM#_________________ CODE#1335-1000
Fire & Casualty
AMT$_____________________
CODE#________
Revised 01/06
COVERAGE TYPE CODES
10 Dwelling fire, vacant dwellings (Fire & Extended Coverage)
20 Commercial fire and extended coverage (Include EC if indicated)
30 Extended coverage (use only if fire is not included)
Other Allied Lines, DIC (Difference in condition) Business interruption, extra expense,
40
loss of income
50 Homeowners
60 Commercial Multi-peril, (package) Special Multi-peril (SMP) Railroads
70 Excess property coverage, flood, excess marine
80 Earthquake
90 Ocean Marine, (ocean boats)
100 Inland Marine
130 Boiler & Machinery
140 Private Passenger Auto Physical damage
145 Excess Private Passenger Auto
150 Commercial auto, car dealers Physical damage
155 Excess Commercial Auto
160 Aircraft: Liability, physical damage
170 Ezcess Cargo Liability
200 Credit: Credit life
210 Fidelity: Forgery, fidelity bonds
220 Surety: Bid, completion bonds
230 Burglary, Theft & Robbery, Kidnap Ransom
240 Glass
250 Product Liability: (use only if products is the only coverages)
260 Medical Malpractice (nurses, ambulance technicians)
261 Professional Liability: Attorneys, accountants, clergymen, etc.
General Liability: Comprehensive general liab. (CGL), owners, landlords and tenants
(OLT) manufacturers and contractors (M&C), completed operations, vehicle service
270
270 contracts) other than excess, XS or 261
contracts) other than excess XS or 261
Errors & Omissions: i.e.: insurance agents, real estate agents, public officials, tax
preparer, architect, Directors and Officers (D&O)
280
290 Excess liability: Umbrella, XS, increased limits liability
300 Accident & Health, Travel, Stop Gap coverage
Other Hole-in-one, prize indemnification, rain, terrorism, other, (please specify in notes
310
specific risk written)
TRANSACTION TYPE CODES
A = AUDIT
C = CANCELATION
E = ENDORSEMENT
N = NEW
R = RENEWAL
INDICATE PAGE OR LINE NUMBER IF A, C, OR E IS USED
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