"Risk Retention Group Business Written & Premium Tax Report" - South Dakota

Risk Retention Group Business Written & Premium Tax Report is a legal document that was released by the South Dakota Department of Labor & Regulation - a government authority operating within South Dakota.

Form Details:

  • Released on July 1, 2018;
  • The latest edition currently provided by the South Dakota Department of Labor & Regulation;
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  • Fill out the form in our online filing application.

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SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATION
DIVISION OF INSURANCE
nd
124 S. Euclid Ave., 2
Floor, Pierre, South Dakota 57501
Tel: 605.773.3563
Fax: 605.773.5369
dlr.sd.gov/insurance
RISK RETENTION GROUP BUSINESS WRITTEN
& PREMIUM TAX REPORT
REPORT OF PREMIUMS COLLECTED AS OF:
(Please check which report is being filed and enter year in space provided, if applicable)
Annual Report as of DECEMBER 31, _______. DUE: APRIL 1
Quarterly Report as of:
st
nd
1
QTR Due: April 30
2
QTR Due: July 31
rd
th
3
QTR Due: Oct 31
4
QTR Due: Jan 31, ____________
NAME:
_____________________________________________
NAIC NO.: ____________
ADDRESS:
_________________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
CONTACT PERSON:______________________________________ PHONE:____________________
(PLEASE PRINT)
EMAIL ADDRESS: ____________________________________________________________________
(REQUIRED)
PART I. DIRECT WRITTEN PREMIUM FOR THE QUARTER
Only Insurers reporting quarterly)
.
(
TOTAL QUARTERLY PREMIUMS WRITTEN
$ _________________
PART II. ANNUAL DIRECT PREMIUM WRITTEN REPORT.
(All insurers complete this section.)
1. Direct Premium Written 1/1/_______ to 12/31/_______:
TOTAL DIRECT PREMIUMS WRITTEN
$ _________________
PART III. PREMIUM TAX CALCULATION
1. SD Direct Written multiplied by Premium Tax Rate of 2.5%
Total Premium Tax =
(1) $ _________________
REV 07/2018
Page 1 of 2
SOUTH DAKOTA DIVISION OF INSURANCE
SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATION
DIVISION OF INSURANCE
nd
124 S. Euclid Ave., 2
Floor, Pierre, South Dakota 57501
Tel: 605.773.3563
Fax: 605.773.5369
dlr.sd.gov/insurance
RISK RETENTION GROUP BUSINESS WRITTEN
& PREMIUM TAX REPORT
REPORT OF PREMIUMS COLLECTED AS OF:
(Please check which report is being filed and enter year in space provided, if applicable)
Annual Report as of DECEMBER 31, _______. DUE: APRIL 1
Quarterly Report as of:
st
nd
1
QTR Due: April 30
2
QTR Due: July 31
rd
th
3
QTR Due: Oct 31
4
QTR Due: Jan 31, ____________
NAME:
_____________________________________________
NAIC NO.: ____________
ADDRESS:
_________________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
CONTACT PERSON:______________________________________ PHONE:____________________
(PLEASE PRINT)
EMAIL ADDRESS: ____________________________________________________________________
(REQUIRED)
PART I. DIRECT WRITTEN PREMIUM FOR THE QUARTER
Only Insurers reporting quarterly)
.
(
TOTAL QUARTERLY PREMIUMS WRITTEN
$ _________________
PART II. ANNUAL DIRECT PREMIUM WRITTEN REPORT.
(All insurers complete this section.)
1. Direct Premium Written 1/1/_______ to 12/31/_______:
TOTAL DIRECT PREMIUMS WRITTEN
$ _________________
PART III. PREMIUM TAX CALCULATION
1. SD Direct Written multiplied by Premium Tax Rate of 2.5%
Total Premium Tax =
(1) $ _________________
REV 07/2018
Page 1 of 2
SOUTH DAKOTA DIVISION OF INSURANCE
2. Deduct: Credits Due (Attach Itemized List or Explanation):
(2) $ _________________
3. Quarterly payments* (If any):
Date
Direct Premium
Date
Check
Amount
Quarter
Due
Written
Paid
Number
Paid
First
4/30
__________
______
_______
$____________
Second
7/31
__________
______
_______
$____________
Third
10/31
__________
______
_______
$____________
Fourth
1/31
__________
______
_______
$____________
Sub-Total of Quarterly Payments:
(3) $ _________________
4. Adjusted Premium Tax Total :
(4) $ _________________
(Line 1 minus Line 2 minus Line 3)
5. Add: Interest, Fines, Penalties** Due (If Any.):
(5) $ _________________
6. Total Amount Due:
(6) $ _________________
(Line 4 plus Line 5)
* An insurer or its representative remitting in excess of five thousand dollars ($5,000.00) premium tax in the previous year
must pay premium taxes on a quarterly basis the following year. [SDCL 58-32-44].
** All taxes and installments paid after the Date Due must include a penalty fee of one and one-half percent (1.5%) per
month, or fraction thereof, on the unpaid balance. [SDCL 10-44-16].
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
State of
_________________________)
County of ________________________)
I, __________________________________, being first duly sworn, say and depose on oath, that I am the
(Name)
_______________________________of ______________________________________, that I am familiar
(Official Title)
(Company Name)
with the subject matter reported in the foregoing document, and that the amounts set forth therein are correct
to the best of my information, knowledge and belief.
_________________________________________________ ________________
(Signature)
(Date)
REV 07/2018
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SOUTH DAKOTA DIVISION OF INSURANCE
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