Form E - Tax Return On Insurance Placed In Surplus Lines Insurers
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1FORM E - TAX RETURN ON INSURANCE PLACED IN SURPLUS LINES INSURERS
(This return must be filed to cover the preceding three-month period. A check covering the taxes due but not otherwise paid should be remitted herewith.)
Item 1
Item 2
Item 3
Item 4
Item5
Item 6
POLICY PERIOD
Gross Return
Gross Premium
Taxable
at 5%
Item 3 less
Total Tax Due
Gross Premium
From
To
Premium On
Policies
Named Insured
Item 4
(5% of Item 5)
Charged on Insurance Placed
TOTAL
$
-
Sworn to and subscribed before me this _________ day of ________________, ________
______________________________________________________
Surplus Lines Licensee
(Notary Public) __________________________________________
For information contact:
Property and Casualty Division
My Commission expires __________________________, _________
NC Department of Insurance
1201 Mail Service Center
Raleigh, NC 27699-1201
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