Form HIPMC-IPO-4 "Quarterly Financial Statement of Insurance Purchasing Outlet" - Kentucky

What Is Form HIPMC-IPO-4?

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 September 1, 2002;
  • 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 HIPMC-IPO-4 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Insurance.

ADVERTISEMENT
ADVERTISEMENT

Download Form HIPMC-IPO-4 "Quarterly Financial Statement of Insurance Purchasing Outlet" - Kentucky

Download PDF

Fill PDF online

Rate (4.7 / 5) 12 votes
Page background image
Commonwealth of Kentucky
Kentucky Department of Insurance
Quarterly Financial Statement of Insurance Purchasing Outlet
In accordance with KRS 304.17A-758(4), an Insurance Purchasing Outlet is required to furnish
Quarterly Financial Statements to the Department no later than sixty (60) days after the end of
the reporting period and an annual Audited Financial Statement on or before one hundred twenty
(120) days from the end of the Insurance Purchasing Outlet’s fiscal year. Following is the form
prescribed by the Commissioner that should be used by an Insurance Purchasing Outlet to
develop the reports. Completed reports should be forwarded to the KY Department of Insurance,
Attention: Division of Financial Standards and Examinations, P.O. Box 517, Frankfort, KY
40602-0517.
(NAME OF INSURANCE PURCHASING OUTLET)
FINANCIAL STATEMENTS AND SCHEDULES
(DATE)
- - - - - - - - - - - - - - - - - - - - - - - - - -
(NAME OF INSURANCE PURCHASING OUTLET)
Table of Contents
Item (or schedule) Page
(LIST ITEMS OR SCHEDULES
AND PAGE NUMBERS HERE)
- - - - - - - - - - - - - - - - - - - - - - - - - -
(NAME OF INSURANCE PURCHASING OUTLET)
Balance Sheet
(Date of Balance Sheet)
Assets
(LIST ALL ITEMS MATERIAL TO THE
INSURANCE PURCHASING OUTLET 'S FINANCIAL CONDITION)
Liabilities and Equity
(LIST ALL ITEMS MATERIAL TO THE
INSURANCE PURCHASING OUTLET 'S FINANCIAL CONDITION)
HIPMC-IPO-4
(9/02)
Page 1 of 3
Commonwealth of Kentucky
Kentucky Department of Insurance
Quarterly Financial Statement of Insurance Purchasing Outlet
In accordance with KRS 304.17A-758(4), an Insurance Purchasing Outlet is required to furnish
Quarterly Financial Statements to the Department no later than sixty (60) days after the end of
the reporting period and an annual Audited Financial Statement on or before one hundred twenty
(120) days from the end of the Insurance Purchasing Outlet’s fiscal year. Following is the form
prescribed by the Commissioner that should be used by an Insurance Purchasing Outlet to
develop the reports. Completed reports should be forwarded to the KY Department of Insurance,
Attention: Division of Financial Standards and Examinations, P.O. Box 517, Frankfort, KY
40602-0517.
(NAME OF INSURANCE PURCHASING OUTLET)
FINANCIAL STATEMENTS AND SCHEDULES
(DATE)
- - - - - - - - - - - - - - - - - - - - - - - - - -
(NAME OF INSURANCE PURCHASING OUTLET)
Table of Contents
Item (or schedule) Page
(LIST ITEMS OR SCHEDULES
AND PAGE NUMBERS HERE)
- - - - - - - - - - - - - - - - - - - - - - - - - -
(NAME OF INSURANCE PURCHASING OUTLET)
Balance Sheet
(Date of Balance Sheet)
Assets
(LIST ALL ITEMS MATERIAL TO THE
INSURANCE PURCHASING OUTLET 'S FINANCIAL CONDITION)
Liabilities and Equity
(LIST ALL ITEMS MATERIAL TO THE
INSURANCE PURCHASING OUTLET 'S FINANCIAL CONDITION)
HIPMC-IPO-4
(9/02)
Page 1 of 3
(Refer to notes, if applicable)
- - - - - - - - - - - - - - - - - - - - - - - - - -
(NAME OF INSURANCE PURCHASING OUTLET)
Statements of Revenue and Expenses
(Dates covered by quarter)
Revenue
(LIST ALL ITEMS MATERIAL TO THE
INSURANCE PURCHASING OUTLET 'S FINANCIAL CONDITION)
Expenses
(LIST ALL ITEMS MATERIAL TO THE
INSURANCE PURCHASING OUTLET 'S FINANCIAL CONDITION)
(Refer to notes, if applicable)
- - - - - - - - - - - - - - - - - - - - - - - - - -
(NAME OF INSURANCE PURCHASING OUTLET)
Statements of Changes in Equity
(Dates covered by quarter)
Equity balance - beginning of year
Contributions & Capital Transactions
Revenue over expenses
Equity balance - end of year
(Refer to notes, if applicable)
- - - - - - - - - - - - - - - - - - - - - - - - - -
(NAME OF INSURANCE PURCHASING OUTLET)
Statements of Cash Flows
(Dates covered by quarter)
Cash flows from operating activities:
Revenue over expenses
Adjustments to reconcile revenue over expenses
HIPMC-IPO-4
(9/02)
Page 2 of 3
(List items and amounts)
Net cash provided by operating activities
Cash flows from investing activities:
(List items and amounts)
Net cash used in investment activities
Cash flows from financing activities
(List items and amounts)
Net increase in cash and cash equivalents
Cash and cash equivalents - beginning of year
Cash and cash equivalents - end of year
(Refer to notes, if applicable)
- - - - - - - - - - - - - - - - - - - - - - - - - -
(NAME OF INSURANCE PURCHASING OUTLET)
Notes to Financial Statements
(Dates covered by quarter)
(List notes including any supplementary information required by the Financial Accounting Standards Board
(FASB) Statements)
HIPMC-IPO-4
(9/02)
Page 3 of 3
Page of 3