Form 115ar Report Of Procurement, Continuance, Or Renewal Of Insurance With Unauthorized Insurer

Form 115ar Report Of Procurement, Continuance, Or Renewal Of Insurance With Unauthorized Insurer - Connecticut

Form 115AR

Department of Revenue Services

State of Connecticut

Report of Procurement, Continuance, or Renewal

PO Box 2990

of Insurance With Unauthorized Insurer

Hartford CT 06104-2990

(Rev. 12/08)

Complete this return in blue or black ink only.

Use Form 115AR, Report of Procurement, Continuance, or Renewal

A separate report is required for each new or renewed insurance

of Insurance With Unauthorized User, to report insurance coverage

contract. You must also ﬁ le Form 115A, Premium Tax Return, and pay

obtained from an unauthorized insurer. File this report with the

a 4% tax on the premium charged for the insurance during the calendar

Commissioner of Revenue Services within 60 days after the date

year on or before March 1 of the following calendar year.

insurance is procured, continued, or renewed with any unauthorized

insurer.

Mail to:

Department of Revenue Services

State of Connecticut

PO Box 2990

Hartford CT 06104-2900

Enter your Connecticut Unauthorized Insurance Tax Registration Number, if any.

Name and Address of Insured

First Name and Middle Initial

Last Name

Address

Number and Street

PO Box

City, Town, or Post Ofﬁ ce

State

ZIP Code

First Name and Middle Initial

Last Name

Address

Number and Street

PO Box

City, Town, or Post Ofﬁ ce

State

ZIP Code

Name and Address of Insurer

Insurer’s Name

Address

Number and Street

PO Box

City, Town, or Post Ofﬁ ce

State

ZIP Code

Insurance Information

Contract number:

Effective date:

Premium charged:

Expiration date:

General description of coverage:

Subject of the insurance:

Declaration: I declare under penalty of law that I have examined this return (including any accompanying schedules and statements) and, to the best

of my knowledge and belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false return to Department of Revenue

Services (DRS) is a ﬁ ne of not more than $5,000, or imprisonment for not more than ﬁ ve years, or both. The declaration of a paid preparer other than the

taxpayer is based on all information of which the preparer has any knowledge.

Signature of Principal Ofﬁ cer

Date

Daytime Telephone Number

(

)

Sign

Print Name of Principal Ofﬁ cer

Title

Here

Keep a copy

Paid Preparer’s Signature