Form LGT-140 "City, County, or Urban County Government Insurance Premium Tax Annual Reconciliation" - Kentucky

What Is Form LGT-140?

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

Form Details:

  • Released on March 1, 2005;
  • The latest edition provided by the Kentucky Department of 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 printable version of Form LGT-140 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Insurance.

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Download Form LGT-140 "City, County, or Urban County Government Insurance Premium Tax Annual Reconciliation" - Kentucky

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DUE: MARCH 31
Commonwealth of Kentucky
Office of Insurance
CITY, COUNTY, OR URBAN COUNTY GOVERNMENT INSURANCE PREMIUM TAX
ANNUAL RECONCILIATION
For the year:
Name of City, County or Urban County Govt.:
FILER INFORMATION
Complete either the information for a direct writer or surplus lines broker depending upon the filer type.
Direct Writer
Surplus Lines Broker
If coverage was exported pursuant to KRS 304.10, please complete
the following:
Insurance Company Name
Individual Broker Name:
:
Street Address:
Name of Broker Firm/Agency:
City, State, ZIP:
Street Address:
Phone:
City, State, ZIP:
FEIN:
Phone:
NAIC No:
Office of Insurance
License ID No:
Person responsible for preparing return:
Name:
Phone:
Title:
E-mail Address:
Street Address:
City, State, ZIP:
SECTION I
(1)
(2)
(3)
(4)
(5)
(6)
Established
Premiums
Tax Payable
Collection
Amount
Additional
Tax Rate %
Collected
[ (1) x (2) ]
Fee
Collected
Tax Due or
From
(Overpayment)
Policyholders
st
1
Quarter
Casualty
Fire & Allied Perils
Health
Inland Marine
Life
Motor Vehicle
All Other Risks
Credits (Form LGT
142)
Total
nd
2
Quarter
Casualty
Fire & Allied Perils
Health
Inland Marine
Life
Motor Vehicle
All Other Risks
Credits (Form LGT
142)
Total
rd
3
Quarter
Casualty
Fire & Allied Perils
Health
Inland Marine
Life
Motor Vehicle
All Other Risks
Credits (LGT 142)
Total
Note: See filing Instructions
Form LGT-140 (03/05)
DUE: MARCH 31
Commonwealth of Kentucky
Office of Insurance
CITY, COUNTY, OR URBAN COUNTY GOVERNMENT INSURANCE PREMIUM TAX
ANNUAL RECONCILIATION
For the year:
Name of City, County or Urban County Govt.:
FILER INFORMATION
Complete either the information for a direct writer or surplus lines broker depending upon the filer type.
Direct Writer
Surplus Lines Broker
If coverage was exported pursuant to KRS 304.10, please complete
the following:
Insurance Company Name
Individual Broker Name:
:
Street Address:
Name of Broker Firm/Agency:
City, State, ZIP:
Street Address:
Phone:
City, State, ZIP:
FEIN:
Phone:
NAIC No:
Office of Insurance
License ID No:
Person responsible for preparing return:
Name:
Phone:
Title:
E-mail Address:
Street Address:
City, State, ZIP:
SECTION I
(1)
(2)
(3)
(4)
(5)
(6)
Established
Premiums
Tax Payable
Collection
Amount
Additional
Tax Rate %
Collected
[ (1) x (2) ]
Fee
Collected
Tax Due or
From
(Overpayment)
Policyholders
st
1
Quarter
Casualty
Fire & Allied Perils
Health
Inland Marine
Life
Motor Vehicle
All Other Risks
Credits (Form LGT
142)
Total
nd
2
Quarter
Casualty
Fire & Allied Perils
Health
Inland Marine
Life
Motor Vehicle
All Other Risks
Credits (Form LGT
142)
Total
rd
3
Quarter
Casualty
Fire & Allied Perils
Health
Inland Marine
Life
Motor Vehicle
All Other Risks
Credits (LGT 142)
Total
Note: See filing Instructions
Form LGT-140 (03/05)
SECTION I (Continued)
(1)
(2)
(3)
(4)
(5)
(6)
Established
Premiums
Tax Payable
Collection
Amount
Additional
Tax Rate %
Collected
[ (1) x (2) ]
Fee
Collected
Tax Due or
From
(Overpayment)
Policyholders
th
4
Quarter
Casualty
Fire & Allied Perils
Health
Inland Marine
Life
Motor Vehicle
All Other Risks
Credits (Form LGT
142)
Total
ANNUAL
TOTALS
Casualty
Fire & Allied Perils
Health
Inland Marine
Life
Motor Vehicle
All Other Risks
Credits (Form LGT
142)
Total
SECTION II
COMPUTATION OF ADDITIONAL PAYMENT DUE
(Do not complete if no additional tax is due for any quarter.)
Total Tax and
Date Tax
Quarter
Tax Balance Due
Annual Interest Rate
Interest Due
Interest Due
Was Paid
st
1
nd
2
rd
3
th
4
Total
SECTION III
Carrier Listing for Exported Coverage
If reporting as a surplus lines broker pursuant to KRS 304.10, please list the carriers that supplied the coverage for which
the premiums and taxes are being reported.*
Carrier Name
NAIC
Annual
Municipal
Carrier Name
NAIC
Annual
Municipal
No.
Premium
Taxes
No.
Premium
Taxes
Collected
Collected
Collected
Collected
*If additional space is needed to list exported carriers, please list the carrier name, NAIC number, and the amount of annual premium collected on a
separate sheet of paper and submit the information with the completed Form LGT 141.
Section IV
Certification
I hereby certify that the information provided is an accurate statement of the premiums collected and that the true and correct amount of taxes due have
been remitted to the city, county, or urban county government named above..
(Signature of Person Responsible For Preparing This Return)
(Date)
Note: See Filing Instructions
Form LGT-140 (03/05)
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