Annual Renewal Form For The City Of Mobile, Alabama,business License For 2012
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1Company:
Phone Number:
Address:
Email Address:
City:
, State:
. Postal Code
Contact:
Account #:
FEIN#:
ANNUAL RENEWAL FORM FOR THE
CITY OF MOBILE, ALABAMA,BUSINESS LICENSE FOR 2012
CERTIFICATE TO BE USED IN REPORTING ALL TYPES OF NEW INSURANCE WRITTEN IN 2011 FOR
THE PURPOSE OF COMPLYING WITH THE CITY OF MOBILE'S BUSINESS LICENSE CODE.
1. Fire and Marine Insurance - New Business: include all fire lines & marine and allied
coverage, including, but not limited to inland marine, ocean marine, and boat owners.
A. Gross premiums, less return premiums, on policies issued during 2011 on property
located within the City limits of Mobile (Code: 524126)
Amount of premiums collected in 2011
$ ___________________
@ 4%=_______________
B. Gross premiums, less return premiums, on policies issued during 2011 on property
located within the Police Jurisdiction of the City of Mobile (Code: 524129).
Amount of premiums collected in
$ ___________________ @ 2%=_______________
2011
2. All Other Insurance - New Business: include all other lines which were not reported in
paragraph 1 (A) and (B), including life, health, accident, surety bonds, public liability,
auto liability and property damage, and all other miscellaneous coverages.
A. Gross premiums, less return premiums, received during 2011 on policies issued
during 2011 to citizens of the City of Mobile (Code: 524113).
Amount of premiums collected in
$ ___________________ @ 1%=_______________
2011
B. Gross premiums, less return premiums, received during 2011 on policies issued
during 2011 to citizens of the City of Mobile's Police Jurisdiction (Code: 524115).
Amount of premiums collected in
$ ___________________ @ .5%=_______________
2011
Issue Fee:
10.00
(*) required for premiums written in category 2-A or 2-B-Flat Fee:
50.00*
TOTAL ___________________
AFFIDAVIT: State of___________________, County of____________________, I,___________________________, am
Duly authorized to make this certificate for: Name of Company:
Mailing Address:
City:
State:
Zip:
And I do hereby certify under oath that the amounts shown above are the total amount of premium revenue defined in section 1 and 2
above collected in 2011 on policies issued by said company on business written by each agent or representative of the Company, and
no deductions taken for reinsurance or dividends paid.
By:______________________________ Title:___________________________
Enclose check with completed affidavit to
:
Dept. #1530
City of Mobile Business Licenses
Post Office Box 11407
Birmingham, AL. 35246-1530
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