"Surplus Lines Insurer Business Written & Premium Tax Report" - South Dakota

Surplus Lines Insurer 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;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the South Dakota Department of Labor & Regulation.

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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
SURPLUS LINES INSURER BUSINESS WRITTEN
& PREMIUM TAX REPORT
DUE: APRIL 1
REPORT OF PREMIUMS COLLECTED AS OF DECEMBER 31, ___________.
(ENTER YEAR)
NAME: __________________________________________________
NAIC NO. _____________
ADDRESS: _________________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
CONTACT PERSON:_____________________________________ PHONE:____________________
(PLEASE PRINT)
EMAIL ADDRESS: ___________________________________________________________________
.
PART I. DIRECT WRITTEN PREMIUM PRODUCER REPORT
(
All insurers complete this section)
List the name & address of all South Dakota Licensed Surplus Line Brokers responsible for placing the
direct business written on South Dakota resident risks, the name and address of the insured, date effective,
policy number and amount of the premium. If not applicable, list business or individual self-procuring.
.
Attach additional pages if necessary
PROD.
TOTAL AMOUNT
NAME
ADDRESS
CLASS*
WRITTEN
1.
2.
3.
TOTAL PREMIUMS WRITTEN $
**
* Producer Classes: (1) South Dakota Surplus Lines Broker
(2) Individual Self-Procured
**This figure must match Part II, Line 3.
PART II. DIRECT PREMIUM WRITTEN REPORT.
(All insurers complete this section.)
1. Direct Premium Written 1/1/_________ to 12/31/__________:
Fire Premium:
.
.
.
.
.
.
.
.
(1)
$___________________
All Other:
.
.
.
.
.
.
.
.
.
(2)
$___________________
___________________
Add: (1) + (2)
Total Direct Written Premium
(3)^ $___________________
===============
^ Cross-check: A.S. - SD State Page & Schedule T.
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
SURPLUS LINES INSURER BUSINESS WRITTEN
& PREMIUM TAX REPORT
DUE: APRIL 1
REPORT OF PREMIUMS COLLECTED AS OF DECEMBER 31, ___________.
(ENTER YEAR)
NAME: __________________________________________________
NAIC NO. _____________
ADDRESS: _________________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
CONTACT PERSON:_____________________________________ PHONE:____________________
(PLEASE PRINT)
EMAIL ADDRESS: ___________________________________________________________________
.
PART I. DIRECT WRITTEN PREMIUM PRODUCER REPORT
(
All insurers complete this section)
List the name & address of all South Dakota Licensed Surplus Line Brokers responsible for placing the
direct business written on South Dakota resident risks, the name and address of the insured, date effective,
policy number and amount of the premium. If not applicable, list business or individual self-procuring.
.
Attach additional pages if necessary
PROD.
TOTAL AMOUNT
NAME
ADDRESS
CLASS*
WRITTEN
1.
2.
3.
TOTAL PREMIUMS WRITTEN $
**
* Producer Classes: (1) South Dakota Surplus Lines Broker
(2) Individual Self-Procured
**This figure must match Part II, Line 3.
PART II. DIRECT PREMIUM WRITTEN REPORT.
(All insurers complete this section.)
1. Direct Premium Written 1/1/_________ to 12/31/__________:
Fire Premium:
.
.
.
.
.
.
.
.
(1)
$___________________
All Other:
.
.
.
.
.
.
.
.
.
(2)
$___________________
___________________
Add: (1) + (2)
Total Direct Written Premium
(3)^ $___________________
===============
^ Cross-check: A.S. - SD State Page & Schedule T.
REV 07/2018
Page 1 of 2
SOUTH DAKOTA DIVISION OF INSURANCE
SURPLUS LINES INSURER BUSINESS WRITTEN & PREMIUM TAX REPORT (cont.)
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
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
Page 2 of 2
SOUTH DAKOTA DIVISION OF INSURANCE
Page of 2