Premium Tax Report Surplus Lines Broker Form - South Dakota Division Of Insurance

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SOUTH DAKOTA DIVISION OF INSURANCE
445 East Capitol Avenue, 1st Floor
Pierre, South Dakota 57501
Main Line (605) 773-3563 Fax: (605) 773-5369
PREMIUM TAX REPORT
SURPLUS LINES BROKER
REPORT OF PREMIUMS COLLECTED AS OF DECEMBER 31, ____________.
DATE DUE: BEFORE APRIL 1
NAME:_____________________________________________________________________________
BUSINESS NAME:___________________________________________________________________
BUSINESS ADDRESS:________________________________________________________________
License Number: __________________________ BUS. PHONE:______________________________
PART I. SURPLUS LINES PREMIUM COLLECTED:
List all Insurance Companies and the premium collected for each company. Attach additional pages if necessary. Also
include the name & address of the insured, effective date & amount of premium written for each policy.
PREMIUM
NAME
ADDRESS
COLLECTED
1.
2.
3.
___________
*
TOTAL PREMIUM WRITTEN $__________
=========
*This amount must equal PART II line 3.
PART II. PREMIUM COLLECTED REPORT:
Total Fire premium collected
(1) $______________________________
Total Other premium collected
(2) $______________________________
Add: (1) + (2) Total Premium Collected
(3) $______________________________
PART III. PREMIUM TAX CALCULATION:
Multiply Line (1) x SD Fire Premium Tax Rate: 3% =
(4) $______________________
Multiply Line (2) x SD All Other Premium Tax Rate: 2.5% = (5) $______________________
________________________
Add: (4) +(5): Total Premium Tax =
(6) $______________________
======================

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