Form LGT141 "City, County, or Urban County Government Quarterly Insurance Premium Tax Return" - Kentucky

What Is Form LGT141?

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 April 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 LGT141 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Insurance.

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Download Form LGT141 "City, County, or Urban County Government Quarterly Insurance Premium Tax Return" - Kentucky

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Commonwealth of Kentucky
Office of Insurance
CITY, COUNTY, OR URBAN COUNTY GOVERNMENT QUARTERLY INSURANCE PREMIUM TAX RETURN
Due 30 Days After Each
Calendar Quarter
For the Quarter:
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:
(1)
(2)
(3)
(4)
(5)
Established
Premiums
Tax Payable
Collection
Amount Collected
Line Of Insurance
Tax Rate %
Collected
[(1) x(2)]
Fee
From
Policyholders
Casualty
Fire & Allied Perils
Health
Inland Marine
Life
Motor Vehicle
All Other Risks
Credits (Form LGT 142)
Total
FORM LGT 141 (04/05)
Commonwealth of Kentucky
Office of Insurance
CITY, COUNTY, OR URBAN COUNTY GOVERNMENT QUARTERLY INSURANCE PREMIUM TAX RETURN
Due 30 Days After Each
Calendar Quarter
For the Quarter:
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:
(1)
(2)
(3)
(4)
(5)
Established
Premiums
Tax Payable
Collection
Amount Collected
Line Of Insurance
Tax Rate %
Collected
[(1) x(2)]
Fee
From
Policyholders
Casualty
Fire & Allied Perils
Health
Inland Marine
Life
Motor Vehicle
All Other Risks
Credits (Form LGT 142)
Total
FORM LGT 141 (04/05)
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
Quarterly
Municipal
Carrier Name
NAIC
Quarterly
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 quarterly premium collected on a
separate sheet of paper and submit the information with the completed Form LGT 141.
Certification
I hereby certify that the information provided is an accurate statement of the premiums collected.
(Signature of Person Responsible For Preparing This Return)
(Date)
NOTE: See Filing Instructions
FORM LGT 141 (04/05)
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