Ocean Marine Tax Report Form - New Jersey Department Of Banking And Insurance
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1
2State of New Jersey
DEPARTMENT OF BANKING AND INSURANCE
PO BOX325
Trenton, NJ 08625-0325
OCEAN MARINE TAX REPORT
Commissioner of Banking and Insurance of State of New Jersey:
The ____________________________________________________________________
Incorporated under the laws of _____________________________________________________
and with offices located at ________________________________________________________
(MAILING ADDRESS OF OFFICE PREPARING RETURN)
hereby submit the following statement for the calendar year ending December 31, ________ , as
required by, and in accordance with the New Jersey Revised Statutes Title 54 Chapters 16, 17, 18
and 18A.
STATE OF ____________________________
COUNTY OF __________________________
On this _____ day of _____________ A.D. _______ before me ____________________
personally appeared _____________________________________________________________
(INSERT SECRETARY OR U.S. MANAGER)
Insurance Company of ___________________________
____________________________________________
who being duly sworn according to law, on his oath did depose and say that the foregoing report
is true and correct.
Subscribed and sworn to before me the ________________________________________
day and year aforesaid.
_______________________________________
_______________________________________
(INSERT SECRETARY OR U.S. MANAGER)
________________________________________
________________________________________
(OFFICIAL TITLE)
Party to contact regarding this return
________________________________________
(NAME AND TITLE)
________________________________________
(PHONE NUMBER)
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